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

 
We decided that the Plan does not have to pre-approve the intracept procedure (CPT code(s): 64628 and 
64629). 
 
You asked the Plan to pre-approve the intracept procedure. You say that the services are necessary. The Plan 
denied your request. The Plan says the services are 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 the 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 to show safety and 
efficacy. 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 intracept procedure have not been met. Therefore, we decided 
that the Plan does not have to pre-approve the intracept procedure (CPT code(s): 64628 and 64629).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ozempic injection. 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied 
your request. The Plan says Medicare guidance says a subcutaneous injection (a shot under the skin) that can be 
self-administered is covered by the pharmacy (drug) benefit. 
 
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 Ozempic injection.   
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anterior instrumentation (CPT code 22845) provided on 
May 5, 2022. You asked the Plan to pay for the service. You say that 22845 was billed with a 59 modifier to unbundle the 
22853. You state the use of 59 is appropriate for 22845 if you use a completely separate plate that spans the 
interspace, it provides independent stabilization, and is not considered integral to the intervertebral device 
(22853). You state that intervertebral device (22853) was used for an interbody spacer and is not used for 
anchoring. You state this was not a combo type device. The Plan denied your request. The Plan says the service 
is 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 22845 
is a column II code to column I code 22853. 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. Furthermore, you 
state that modifier 59 was added to 22845; however, a review of claim history did not find a claim submission 
where the 59-modifier had been added to 22845. Therefore, we decided that the Plan does not have to pay for 
the anterior instrumentation (CPT code 22845) provided on May 5, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair and accessories (K0861, E2300, 
E1007, E1012, E2311, E2331, K0108). 
 You asked the Plan to pre-approve a power wheelchair and accessories. You say that you are requesting 
reconsideration of approval for the power wheelchair due to osteoarthritis in the left hip. The Plan denied your 
request. The Plan says you were supplied a power wheelchair in 2020 which is currently in disrepair. The 
repair of this wheelchair has been previously approved. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that you have a Quickie Q500 wheelchair. The Quickie Q500 serves the same purpose as the 
requested power wheelchair and accessories. Medicare rules show that the reasonable useful lifetime of 
equipment in no case can be less than 5 years. The records show that the Plan has approved repairs to your 
current wheelchair. Therefore, we decided that the Plan does not have to pre-approve a power wheelchair and 
accessories (K0861, E2300, E1007, E1012, E2311, E2331, K0108).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services rendered on April 25, 2022, to May 
24, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that HHAs must send a Notice of Admission (NOA) to 
Medicare by mail, electronic data interchange (EDI), or direct data entry (DDE). 
 
We looked at the file and Medicare rules. The file shows that a valid NOA was not submitted for the dates of 
service at issue. 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 pay for the home health services rendered 
on April 25, 2022, to May 24, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on February 17, 2022. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the claim was 
billed with the incorrect date of service. 
 
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 payment for CPT code 81455 is not supported in the medical record. Specifically, the claim must 
be billed with the date the specimen was collected. The records show that the specimen was collected on 
February 12, 2021. As such, the claim was billed with the incorrect date of service. Based on this information, 
we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that 
the Plan does not have to pay for the lab services provided on February 17, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (27447) provided on March 18, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says payment is included in 
the global surgery payment. 
 
The Plan must follow Medicare rules. Medicare rules say that the Medicare approved amount for global 
surgery procedures includes payment for services related to the surgery when furnished by the physician who 
performs the surgery..  
 We looked at the file and Medicare rules. Payment for the requested services (27447) is included in the global 
surgery payment for the procedure (64640) provided on March 10, 2022, which has a 10-day global period. 
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 (27447) provided on March 18, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a diabetic shoe (A5500). 
 
You asked the Plan to pre-approve a diabetic shoe. You say that you disagree with the denial as you were 
previously given a standard diabetic shoe that was not sufficient to meet your medical needs. The Plan denied 
your request. The Plan says a diabetic shoe and inserts were provided to you for the 2022 plan year. You have 
exhausted this benefit for the 2022 calendar year. 
 
The Plan must follow Medicare rules. Medicare rules say that for beneficiaries meeting the coverage criteria of 
a diabetic shoe, coverage is limited to one diabetic shoe per calendar year.  
 
We looked at the file and Medicare rules. The records show that you received a diabetic shoe and inserts on 
March 12, 2022, therefore, you have exhausted the benefit for the requested shoe. Based on this information, 
we decided that Medicare rules for coverage of a diabetic shoe have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a diabetic shoe (A5500).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the x-ray services rendered on December 14, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. 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 24, 2021. 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 these services have not been met. Therefore, 
we decided that the Plan does not have to pay for the x-ray services rendered on December 14, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0676) provided on 
February 10, 2022. 
 
You asked the Plan to pay for a pneumatic compression device. You say that you disagree with the denial and 
are requesting payment for this claim. The Plan denied your request. The Plan says the requested 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 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 
pay for a pneumatic compression device (E0676) provided on February 10, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a breast mammography (code 77067) and screening digital 
breast tomosynthesis, bilateral (code 77063) provided on June 18, 2021. 
 
You asked the Plan to pay for a breast mammography (code 77067) and screening digital breast tomosynthesis, 
bilateral (code 77063). 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 June 22, 2022. 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 a breast mammography (code 77067) and screening digital breast tomosynthesis, bilateral (code 77063) have not been met. Therefore, we decided that 
the Plan does not have to pay for a breast mammography (code 77067) and screening digital breast 
tomosynthesis, bilateral (code 77063) provided on June 18, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics. 
 
You asked the Plan to pre-approve foot orthotics. You say that you have had botched surgeries and feel that the 
Plan should cover the orthotics. The Plan denied your request. The Plan says you have a diagnosis of type 2 
diabetes, but you do not have a diabetic foot at risk or any qualifying diagnosis for foot orthotics. Therefore, 
this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Tezspire 210MG solution. 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied 
your request. The Plan says Medicare guidance says subcutaneous injection (a shot under the skin) that can be 
self-administered is covered by the pharmacy (drug) benefit. 
 
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 Tezspire 210MG solution.   
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 74018 billed for date of service March 30, 
2022. 
 
You asked the Plan to pay for procedure code 74018. You say that you disagree with the denial. The Plan 
denied your request. The Plan says payment for code 74018 is bundled into payment for code 74250. 
 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 74018 
is a column II code to column I code 74250. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 74018 billed for date of service March 30, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Zarxio (CPT code Q5101). 
 
You asked the Plan to pre-approve the medication. You say that the medication is medically necessary. The 
Plan denied your request. The Plan says the information they have says you are in a clinical trial.  
The Plan must follow Medicare rules. The rules say that Original Medicare pays for the routine costs of 
qualifying clinical trials. Enrollees in a Medicare plan receive the same coverage for qualifying clinical trials as 
people enrolled in Original Medicare. The Plan must cover only the difference between the cost-sharing in 
Original Medicare and the plan cost-sharing for the same services. 
 
In this case, you asked the Plan to pre-approve the medication as part of a clinical trial. The Plan does not cover 
routine costs associated with qualifying clinical trials. Therefore, we decided that the Plan does not have to pre-
approve Zarxio (CPT code Q5101).
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 there is no available nearby skilled nursing facility. 
The Plan denied your request. The Plan says IRF care 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 that the enrollee is functioning at a home care level for rehabilitation. The enrollee 
does not require intensive rehabilitation or frequent physiatry oversight. This is a request to utilize hospital-based services to address social limitations for an enrollee who lives alone. An IRF level of care 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 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 you live alone and need IRF care. The Plan denied 
your request. The Plan says an intensive rehabilitation program 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 that the complexity of your nursing, medical and rehabilitation needs does not require 
an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical problems are stable. There are no complex nursing or rehabilitation needs. While the documentation does support a need for 
physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary 
rehabilitation program. There is not a reasonable expectation that you will be able to fully participate in and 
benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for revascularization services (procedure code 37222 and 37233) 
provided to the enrollee on April 24, 2022. 
 
You asked the Plan to pay for the services. You say that the medical records should be reviewed and both codes 
should be considered for payment. The Plan denied your request. The Plan says the denied codes are not 
supported by the medical records. 
 
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 the denied codes is: 
 
CPT 37222: 
 
revascularization, endovascular, open or percutaneous, iliac artery, each additional ipsilateral iliac vessel; with 
transluminal angioplasty (List separately in addition to code for primary procedure) 
 
 CPT 37233: 
 
revascularization, endovascular, open or percutaneous, tibial/peroneal artery, unilateral, each additional vessel; 
with atherectomy, includes angioplasty within the same vessel, when performed (List separately in addition to 
code for primary procedure) 
 
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 services at issue in 
this case were not supported by the medical records. Our reviewer found that the operative report did not 
include documentation of an open or percutaneous endovascular iliac artery, each additional ipsilateral iliac 
vessel; with transluminal angioplasty which is used for procedure code 37222-RT. Additionally, the medical 
documentation does not include documentation for procedure code 37233-RT. 
 
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 revascularization services (procedure code 37222 and 37233) provided to the enrollee on April 
24, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implantable neurostimulator, pulse generator 
(L8679). 
 
You asked the Plan to pre-approve an implantable neurostimulator. You say that you have a diagnosis of pain 
in the left thigh however there is no mention of left thigh pain. Provider letter and clinicals have been attached 
to justify approval. The Plan denied your request. The Plan says you do not have a condition for which this 
treatment is medically necessary. You have not had psychological therapy, surgical treatment or records show 
that you are not a surgical candidate. The Plan must follow Medicare rules. Medicare rules say that this item and/or service is covered under certain 
conditions.  
 
We looked at the file and Medicare rules. The records show that you do not have a condition for which this 
treatment is medically necessary, therefore, you do not meet the requirements for approval of this service. 
Based on this information, we decided that Medicare rules for coverage of an implantable neurostimulator have 
not been met. Therefore, we decided that the Plan does not have to pre-approve an implantable neurostimulator, 
pulse generator (L8679).