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

 
We decided that the Plan does not have to pre-approve destruction by neurolytic agent, paravertebral facet joint 
nerve(s), with imaging guidance (fluoroscopy or computerized tomography (CT)); lumbar or sacral, single 
facet joint (64635) and each additional facet joint (64636). 
 
You asked the Plan to pre-approve the services. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the medical records do not show that the enrollee has had a failure of at 
least three (3) months of conservative/conventional therapies such as pain medications, physical therapy, and 
an ongoing home exercise and strengthening/conditioning program for the enrollee's back pain. 
 
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 services. Our physician reviewer 
found there is no documentation of a failure of at least three (3) months of conservative/conventional therapies 
such as pain medications, physical therapy, and an ongoing home exercise and strengthening/conditioning 
program for his back pain. The review has determined that the medical records provided do not meet the 
requirements listed in the LCD for Medicare coverage. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance 
(fluoroscopy or computerized tomography (CT)); lumbar or sacral, single facet joint (64635) and each 
additional facet joint (64636).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the injection procedure for sacroiliac (SI) joint, 
anesthetic/steroid, with image guidance (fluoroscopy or computerized tomography (CT)) including 
arthrography when performed (27096). 
 
You asked the Plan to pre-approve the injection. You say that the service is medically necessary. The Plan 
denied your request. The Plan says the Medicare rules have not been 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 the injection. Our physician reviewer 
found the records do not have documentation of at least three positive findings with provocative maneuvers: 
FABER, Gaenslen, Thigh Thrust or Posterior Shear, SI Compression, SI Distraction and Yeoman Tests. 
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 the injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the injection procedure for sacroiliac (SI) joint, anesthetic/steroid, with image guidance 
(fluoroscopy or computerized tomography (CT)) including arthrography when performed (27096).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nerve conduction studies (95908) and needle 
electromyography (95886) provided on November 21, 2022. 
 
You asked the Plan to pay for the services. You say that these services were necessary and are supported as 
billed. The Plan denied your request. The Plan says these services are not supported in the medical record. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 95908 is nerve conduction studies; 3-4 studies. The 
definition of code 95886 is needle electromyography, each extremity, with related paraspinal areas, when 
performed, done with nerve conduction, amplitude and latency/velocity study; complete, five or more muscles 
studied, innervated by three or more nerves or four or more spinal levels (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 found for code 95908, the 
documentation submitted was reviewed, and does not meet criteria. The procedure report described," Pedicle 
screw stimulation", which is not considered nerve conduction studies (amplitude and latency/velocity); 
therefore, this procedure cannot be verified. For code 95886, the documentation submitted was reviewed, and 
does not meet criteria. Per code description, "done with nerve conduction, amplitude and latency/velocity 
study", in this case documentation does not support nerve conduction studies; therefore, this procedure would 
not be covered, as the code description was not documented. 
 
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 nerve conduction studies (95908) and needle electromyography (95886) provided on 
November 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chronic care management (CCM) services (procedure code 
99490) rendered on November 10, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the records do not support any documentation of the billing provider having an initiating face-to-
face visit separate of the chronic care management service (CCM). 
 
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 99490 is "Chronic care management services with the 
following required elements: multiple (two or more) chronic conditions expected to last at least 12 months, or 
until the death of the patient, chronic conditions that place the patient at significant risk of death, acute 
exacerbation/decompensation, or functional decline, comprehensive care plan established, implemented, revised, or monitored; first 20 minutes of clinical staff time directed by a physician or other qualified health 
care professional, per calendar month." 
 
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 medical record does not 
include enough information to confirm CCM services was initiated by the provider during comprehensive 
evaluation and management service. Therefore, this service cannot be verified.  
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for chronic care management (CCM) services (procedure code 99490) rendered on November 10, 
2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM) kit 
sensor. 
 
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 criteria are not met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not treat with 
insulin three or more times per day or use an insulin pump. 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 a Freestyle Libre continuous glucose monitor (CGM) kit sensor.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for initial observation care (procedure code 99219) rendered on March 17, 
2021 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says that Current Procedural Terminology (CPT) code 99219 remains 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 99219 is "Initial observation 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 moderate 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 to outpatient hospital "observation status" 
are of moderate severity. Typically, 50 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 services at issue in 
this case were supported by the medical records. Our reviewer found that the patient complained of abdominal 
pain and constipation.  While the complaint itself may seem relatively minor, the documented history is 
comprehensive. As such the billing of CPT 99219 is 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 the services have been met. Therefore, we decided that the Plan has to pay for 
initial observation care (procedure code 99219) rendered on March 17, 2021  
 
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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health care. 
 You asked the Plan to pre-approve home health services. You say that you need home health care every week. 
The Plan denied your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found the 
documentation doesnt support that you require additional skilled nursing services to provide treatment that is 
medically necessary. You do not require additional skilled nursing services to effectively provide treatment, 
care, and/or services in order to improve your condition, perform a maintenance program to maintain your 
condition and/or prevent deterioration.  You have been medically stable without any recent exacerbations of 
chronic medical problems or hospitalizations.  The requested home health services are 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 home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home health care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you are concerned that the enrollee will 
not have a good outcome if they are not managed appropriately. The Plan denied your request. The Plan says 
they will continue to cover medically necessary acute and critical care at the current facility until the enrollee's 
condition is stable for transfer to an alternate level of care. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
 
 
 
 
 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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee was admitted for elective below the knee amputation and has had a 
complicated postoperative course.  The record indicates that the enrollee has ongoing acute medical issues and 
still requires acute care services.  The enrollee continues to receive acute care services, and these have not been 
denied.  The medical record does not indicate that the enrollee requires services that they are not currently 
receiving but that would be available at the LTACH facility.  The elements of the coverage rules are not 
satisfied. 
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Keytruda 200 milligrams (MG) intravenous. 
 
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 that this request does not meet the criteria or medical necessity. 
 
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 the medication. Our physician reviewer 
found this medication is used as second-line systemic therapy post-platinum or other chemotherapy as a single 
agent (preferred) for metastatic stage IVB (any T, any N, M1b) disease. 
 
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 medication have been met. Therefore, we decided that the Plan has to pre-
approve Keytruda 200 milligrams (MG) intravenous.  
 
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: 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 you require the therapy and level of care provided in 
a SNF. The Plan denied your request. The Plan says that SNF services are 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 you do not require daily skilled nursing and/or skilled therapy services. You are 
medically stable and can receive further rehabilitation services at a lower 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency department services (procedure code 99285) 
rendered on October 19, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says CPT 99285 was downcoded to CPT 99284. 
 
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 99285 is "Emergency department visit for the evaluation 
and management of a patient, which requires these 3 key components within the constraints imposed by the 
urgency of the patient's clinical condition and/or mental status: 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 presenting problem(s) are of high 
severity and pose an immediate significant threat to life or physiologic function." 
 
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 in this case, the documentation 
does not support the CPT code 99285. The documentation available for review does not support that the 
presenting problems were of high severity or that the medical decision was 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 emergency department services (procedure code 99285) rendered on October 19, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to provide coverage for additional routine transportation mileage. 
 
You asked the Plan to provide coverage for additional routine transportation mileage. You say that additional 
routine transportation mileage is needed. The Plan denied your request. The Plan says your benefit only allows 
50 miles. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case.  
 
We looked at your request, the records in the case file, and the rules. The file shows that the Plans routine 
transportation benefit covers 50 miles of driving distance for each one-way trip. Based on this information, we 
decided that the Plans rules for coverage of routine transportation have not been met. Therefore, we decided 
that the Plan does not have to provide coverage for additional routine transportation mileage.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the laboratory services (81219, 81339, 81279). 
 
You asked the Plan to pre-approve the laboratory services. You say that the services are medically necessary to 
allow for a more accurate diagnosis, tailored treatment plans and more effective monitoring of the enrollee's 
condition. The Plan denied your request. The Plan says your request is not medically necessary because the 
enrollee's records do not show the results of BCR-ABL or JAK2 V617F testing, which is required as first steps 
in the sequential testing as required by the Medicare Guidelines. 
 
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 laboratory services. Our physician 
reviewer found the records do not show the results of BCR-ABL or JAK2 V617F testing, which is required as 
first steps in the sequential testing as required by the Medicare Guidelines. The review has determined that the 
medical records provided meet the requirements listed in the LCD for Medicare coverage. 
 
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 laboratory services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the laboratory services (81219, 81339, 81279).