Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet injections. 
 
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 the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that facet injections are covered 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found that the enrollee has low back and 
coccygeal pain due to coccydynia. He has been treated with medications, including opiates, and coccyx 
injections. The injection on May 10, 2022 provided 25 percent relief in pain, the injection on October 13, 2022 
provided 70 percent relief in pain, and the injection on November 8, 2022 had no improvement. The prior 
therapeutic injections did not result in consistent 50 percent pain relief for at least three months. The criteria for 
coverage are not met; therefore, the facet injections are 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve facet injections.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee requires physician oversight and 
frequent monitoring at least 3 times per week as their needs cannot be met in a lower level of care. The Plan 
denied your request. The Plan says an IRF admission is not medically necessary, and the enrollee's needs can 
be met at an alternate level of care. 
 
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 that the enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
level of care. 
 
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 IRF admission and services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Abraxane and Keytruda. 
 
You asked the Plan to pre-approve Abraxane and Keytruda. 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 may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Abraxane and Keytruda. Our reviewer 
says that the services are not medically necessary. Our physician reviewer found per NCCN compendia 
keytruda need estimated glomerular filtration rate (egfr) and anaplastic lymphoma kinase (alk) wildtype. 
Abraxane is used for squamous histology with carbo and Keytruda. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Abraxane and Keytruda have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Abraxane and Keytruda.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 92929 billed for date of service July 6, 2022. 
 
You asked the Plan to pay for procedure code 92929. You say that this service was medically necessary. The 
Plan denied your request. The Plan says procedure code 92929 is considered bundled and 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 procedure code. 
 
We find that procedure code 92929 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 92929 is not separately payable. Based on this information, we decided that Medicare rules for coverage of procedure code 92929 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 92929 billed for date of service July 6, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (99233) provided on June 27, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code is 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 99233 is "Subsequent hospital care, per day, for the 
evaluation and management of a patient, which requires at least 2 of these 3 key components: A detailed 
interval history; A detailed examination; Medical decision making of high complexity. Counseling and/or 
coordination of care with other physicians, other qualified health care professionals, or agencies are provided 
consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the patient is 
unstable or has developed a significant complication or a significant new problem. Typically, 35 minutes are 
spent at the bedside and on the patient's hospital floor or unit". 
 
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 services. Our reviewer says that the use of code 99233 is 
not supported by the records provided. Our reviewer found that the records do not document medical decision 
making of high complexity. 
 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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for the services (99233) provided on June 27, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Otezla. 
 
You asked the Plan to pre-approve Otezla. You say that this drug is medically necessary for the enrollee. The 
Plan denied your request. The Plan says Otezla is not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Otezla.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 36000 billed for date of service May 9, 2022. 
 
You asked the Plan to pay for procedure code 36000. The Plan denied your request. The Plan says procedure 
code 36000 is considered bundled and 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 procedure code. 
 
We find that procedure code 36000 has a status indicator of B on the Physician Fee Schedule. This means that procedure code 36000 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 36000 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 36000 billed for date of service May 9, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99233 provided on February 11, 2022. 
 
You asked the Plan to pay for procedure code 99233. You say that the medical records support the billing of 
procedure code 99233. The Plan denied your request. The Plan says the medical records do not support the 
billing of procedure code 99233. 
 
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 99233 is Subsequent hospital care, per day, for the 
evaluation and management of a patient, which requires at least 2 of these 3 key components: A detailed 
interval history; A detailed examination; Medical decision making of high complexity. Counseling and/or 
coordination of care with other physicians, other qualified health care professionals, or agencies are provided 
consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the patient is 
unstable or has developed a significant complication or a significant new problem. Typically, 35 minutes are 
spent at the bedside and on the patient's hospital floor or unit. 
 
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 code 99233. Our reviewer says that the medical 
records do not support the billing of procedure code 99233. Our reviewer found the progress note does not 
contain a detailed interval history or medical decision making of high complexity. As such, the billing of CPT 
code 99233 on February 11, 2022, is not supported. 
 
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 code 99233 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 99233 provided on February 11, 2022.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for radiological services billed with code 71046 provided on September 19, 
2022. 
 
You asked the Plan to pay for radiology services provided. You say that the claim was billed correctly and 
should be paid. The Plan denied your request. The Plan says that a procedural modifier is required. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. We find that there is no evidence that the enrollee was in a skilled nursing 
facility at the time services were provided. The service was provided in an office setting and billed as such. No 
modifier was needed for payment of the billed code. Therefore, we decided that the Plan has to pay for 
radiological services billed with code 71046 provided on September 19, 2022.  
 
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: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve epidural steroid injections. 
 
You asked the Plan to pre-approve epidural steroid injections. You say that you are in pain and can't take 
steroids or hydrocodone. The Plan denied your request. The Plan says that there is no imaging study that shows 
narrowing of the spine in the mid-back. The medical records show that you have cervical region, not thoracic, 
pain. The request is for epidural steroid injection at levels T1-T2. The scan that you had does not go beyond 
T1. 
 
"The Plan follows Medicare rules. Medicare rules say that epidural steroid injections are coverable when the 
patient has lumbar, cervical, or thoracic radiculopathy, radicular pain and/or neurogenic claudication due to 
disc herniation, osteophyte or osteophyte complexes, severe degenerative disc disease, producing foraminal or 
central spinal stenosis. In addition, the pain must be present for at least four weeks and conservative care has 
been tried and failed. 
 
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 epidural steroid injections are medically necessary for you. Our physician reviewer found 
you have chronic neck pain with radiation to the arms.  You have had a month of physical therapy and home 
exercise and take Tylenol and hydrocodone for pain.  You have a past surgical history of right C5 and C6 
foramenotomoies, and your Magnetic Resonance Imaging shows spinal stenosis. As a result, the doctor finds 
that you meet coverage criteria and the requested epidural steroid injections are 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 epidural steroid injections have been met. Therefore, we decided that the Plan 
has to pre-approve epidural steroid injections.   
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve innovamatrix ac, per square centimeter (A2001). 
 
You asked the Plan to pre-approve wound care. You say that you are requesting reconsideration. There are 
additional medical records enclosed. The Plan denied your request. The Plan says the records do not show that 
there has been an assessment of blood flow and correction of any amenable vascular problems. The enrollee 
continues to have evidence of cellulitis of the toe. Despite this, his toe is showing signs of improvement. 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 wound care. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found it is well established in the medical documentation that this injured worker has a hemoglobin 
A1c within normal limits (5.2), and the medical documentation also supports that the ulceration is 
healing/improving with each debridement visit. Medicare advises that they pay for items or services that are 
reasonable and necessary for the diagnosis or treatment of an illness or injury. This treatment must be safe and 
effective, not mainly for the convenience of the enrollee or the physician, not experimental or investigational, 
appropriate in that it is furnished in accordance with accepted standards of medical practice for the diagnosis or 
treatment of the enrollees condition or to improve the function of a malformed body member, one that meets 
but does not exceed the enrollees medical need, and at least as beneficial as existing and available medically 
appropriate alternatives. In this particular case, the most recent progress note advises that the enrollees 
ulceration is closing/improving with standard wound care. It appears, at this point, that the application of 
innovamatrix graft would exceed the enrollees medical need.  If at any point the ulceration stalls or worsens, 
then innovamatrix graft could be considered at that 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 wound care have not been met. Therefore, we decided that the Plan does not 
have to pre-approve innovamatrix ac, per square centimeter (A2001).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0676). 
 
You asked the Plan to pre-approve a pneumatic compression device. You say that this device is medically 
necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pre-approve a pneumatic compression device (E0676).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99223 billed for date of service August 30, 
2022. 
 
You asked the Plan to pay for the billed services. You say that the records clearly support the level of care 
submitted. The Plan denied your request. The Plan says the records do not support the billed code. 
 
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 99223 is initial hospital care, per day, for the evaluation 
and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and medical decision making of high complexity. Counseling and/or coordination 
of care with other physicians, other qualified health care professionals, or agencies are provided consistent with 
the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring 
admission are of high severity. 
 
 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 billed services. Our reviewer found that 
the progress note does not contain a comprehensive history of the present illness, a comprehensive examination 
or high-complexity medical decision making. As such, the billing of CPT 99223 is not supported. 
 
We looked at this physicians review, the file, and Medicare rules. 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 procedure code 99223 billed for date of service August 30, 2022.
Appeal type: Imaging
Decision: Partially Favorable

 
We decided that the Plan has to pay for the services described by procedure code(s) 61624, 61624, 36226, 
36225, 36227, 36012, 76937, 75898, and 75894. We decided that the Plan does not have to pay for the services 
described by procedure code(s) 75860.  
 
You asked the Plan to pay for Imaging services provided on October 26, 2022.. You say that the claim was 
billed correctly and should be paid. The Plan says that code 75860 is bundled to code 75898. 
 
We decided that the Plan has to pay for the services described by procedure code(s) 61624, 61624, 36226, 
36225, 36227, 36012, 76937, 75898, and 75894.  
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan did not make an appeal decision for the codes listed in this 
section. The Plan is not allowed to reopen any determinations while an appeal is pending and must issue a 
determination on all appealed services within the appeal time frame. As the Plan forfeited its opportunity to 
provide a denial rationale for these services, we find that the denial of payment is not supported. Therefore, we 
decided that the Plan has to pay for the services described by procedure code(s) 61624, 61624, 36226, 36225, 
36227, 36012, 76937, 75898, and 75894.  
 
We also decided that the Plan does not have to pay for the services described by procedure code(s) 
75860. 
 
The Plan follows 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 75860 is a 
column II code to column I code 75898. 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 services described by procedure code(s) 75860. 
 
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.