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

 
We decided that the Plan does not have to pre-approve the destruction by neurolytic agent, paravertebral facet 
joint (64635) and destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance 
(fluoroscopy or CT); lumbar or sacral, each additional facet joint) (64636). 
 
You asked the Plan to pre-approve the repeat radiofrequency ablation (RFA) procedure. You say that you 
would like to appeal because you are in a lot of pain. You have had 5 disks removed and 7 surgeries. The Plan 
denied your request. The Plan says the records do not support that the enrollee meets the criteria for repeat 
radiofrequency ablation. 
 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 repeat radiofrequency ablation 
(RFA) procedure. Our reviewer says that the requested items/services are not considered medically reasonable 
and necessary in this case. Our physician reviewer found the enrollee had RFA of the right L4-S1 medial 
branches on June 1, 2022, but then had medial branch blocks again on September 29, 2022, and November 14, 
2022. The records do not show that the enrollee had a minimum of 50% reduction in pain for at least 6 months 
following previous radiofrequency ablation. 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 repeat radiofrequency ablation (RFA) procedure have not been met. 
Therefore, we decided that the Plan does not have to pre-approve the destruction by neurolytic agent, 
paravertebral facet joint (64635) and destruction by neurolytic agent, paravertebral facet joint nerve(s), with 
imaging guidance (fluoroscopy or CT); lumbar or sacral, each additional facet joint) (64636).
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 the enrollee is medically stable to transfer to a lower 
level of care, however, the enrollee requires additional care and therapy to return to their prior level of function. 
The Plan denied your request. The Plan says the requested 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 the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. 
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Vertiflex procedure (22869). 
 
You asked the Plan to pre-approve a Vertiflex procedure. You say that the requested services are a medical 
necessity for the enrollee. The Plan denied your request. The Plan says the requested services are 
experimental/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 a Vertiflex procedure. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that current evidence-based medical guidelines and peer-reviewed literature do not 
fully support the spinal decompression device procedure over the gold standard of lumbar laminectomy. 
There is a lack of large-volume, long-term, peer-reviewed outcome studies to support the use of the requested device for the enrollees 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 Vertiflex procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Vertiflex procedure (22869).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve electronic brachytherapy (0394T, 77280, 77290). 
 
You asked the Plan to pre-approve electronic brachytherapy. You say that the requested services are a medical 
necessity for the enrollee. The Plan denied your request. The Plan says the requested services are 
experimental/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 electronic brachytherapy. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the requested procedure is experimental/investigational for the squamous cell 
carcinoma in situ. The requested services are not a standard 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 electronic brachytherapy have not been met. Therefore, we decided that the Plan 
does not have to pre-approve electronic brachytherapy (0394T, 77280, 77290).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (00840, 64488) provided on September 30, 
2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed codes cannot 
be verified. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment.  
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the services have been met. The 
submitted documentation does not contain medical records for the date of service in question. Therefore, we 
decided that the Plan does not have to pay for the services (00840, 64488) provided on September 30, 2022.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve a diagnostic sacroiliac (SI) joint injection. 
 
You asked the Plan to pre-approve the SI joint injection. You say that this treatment is medically needed. The 
Plan denied your request. The Plan says that this cannot be covered since the enrollee has spinal stenosis with 
radiculopathy. 
 
The Plan follows Medicare rules. Medicare rules say that SI joint injections may be covered when the criteria 
from 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 the SI joint injection. Our reviewer says 
that the SI joint injection is shown to be medically reasonable and necessary. Our physician reviewer found the 
enrollee suffers from low back pain and has had previous facet joint injections and epidural steroid injections. 
She has pain that radiates bilaterally into her medial thigh. No pain goes below her knees. She has spinal 
stenosis at L3-L4 level. On physical examination, she has three positive physical signs of sacroiliitis. 
 
The enrollee has the required number of physical findings of sacroiliitis, and while she does have spinal 
stenosis, this is associated with a different pain pattern. As such, the request for a diagnostic SI joint injection is 
warranted. 
 
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 SI joint injection have been met. Therefore, we decided that the Plan has to 
pre-approve a diagnostic sacroiliac (SI) joint injection.  
 
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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the initial nursing facility care (99305) provided on 
December 15, 2022, by an out-of-network (OON) provider. 
 
  You asked the Plan to pay for the initial nursing facility care. You say that the provider has no prior knowledge 
of which patients they will be required to see. You also say that since most patients require urgent care, it is not 
possible to request authorization before services are rendered. The Plan denied your request. The Plan says the 
provider that you identified to provide this service, does not participate with the Plan. The Plan also says that 
this service was rendered without authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the initial nursing facility care (99305) provided 
on December 15, 2022, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 36556, 99292, and 99292-GC provided on 
January 18, 2022, and January 20, 2022. 
 You asked the Plan to pay for procedure codes 36556, 99292, and 99292-GC. You say that you would like the 
Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are 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, the CPT Code Manual definition of code 36556 is Insertion of non-tunneled centrally inserted 
central venous catheter; age 5 years or older. The definition of code 99292 is Critical care, evaluation and 
management of the critically ill or critically injured patient; each additional 30 minutes (List separately in 
addition to code for primary service). 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for procedure codes 36556, 99292, and 99292-GC. Our reviewer 
says that the medical records do not support the billing of codes 36556 provided on January 18, 2022, and 
99292-GC provided on January 20, 2022. Our reviewer found the enrollee was treated in the hospital for 
nausea and vomiting, head trauma, and cardiac arrest following a ground level fall. He was intubated and 
sedated. He received critical care, however, the code, 99292, cannot be confirmed as there was no 
documentation provided of the time duration of the evaluation and management of critical care. Also, the 
records describe the enrollee as having had a radial arterial line placed and a right femoral line placed, but no 
procedure note was found in the provided documentation of a central catheter placement to justify the code, 
36556. Therefore, the provided medical records do not support these codes. 
 
Additionally, we have confirmed that code 99292 provided on January 18, 2022, is a column II code to column 
I code 31500. This claim has not been billed with an appropriate modifier to bypass the edit. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 36556, 99292, and 99292-GC have not been met. Therefore, 
we decided that the Plan does not have to pay for procedure codes 36556, 99292, and 99292-GC provided on 
January 18, 2022, and January 20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99233 provided on June 9, 2022. 
 
You asked the Plan to pay for procedure code 99233. You say that the medical records support the billing of 
code 99233. The Plan denied your request. The Plan says the medical records do not support the billing of 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 code 99233. Our reviewer found the enrollee was treated in the hospital for 
depression, suicide attempt, and medication overdose. The documentation for these dates did not describe a 
detailed history or physical examination although they were basic and focused. The enrollee was treated with a 
sitter, fall precautions, regular diet, and psychiatry was consulted. There was insufficient evidence of medical 
decision-making of high complexity. Therefore, the code, 99233 is not sufficiently supported in the provided 
documentation. 
 
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 June 9, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on August 24, 2021, 
through August 31, 2021, and billed with diagnosis code N17.9. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that primary 
diagnosis code N17.9 is supported by the records. The Plan denied your request. The Plan says the 
documentation submitted does not support primary diagnosis of N17.9. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with primary diagnosis code N17.9-Acute kidney failure, 
unspecified. 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 inpatient hospital services at the 
DRG originally billed. Our reviewer says that the documentation does not support the primary diagnosis of 
N17.9-Acute kidney failure, unspecified. Our physician reviewer found the member presented with weakness, 
fatigue, weight loss. The member was diagnosed with failure to thrive. The member's workup revealed an 
initial creatinine level of 1.42, documented as likely due to dehydration. The member was given intravenous 
ceftriaxone fluids and repeat creatinine was at 0.85 (normal). Due to the initial response to the fluids, the 
member does not meet criteria for acute kidney failure. Therefore, diagnosis code N17.9-Acute kidney failure, 
unspecified is the not the appropriate primary diagnosis. 
  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on August 24, 2021, through August 31, 2021, and billed with 
diagnosis code N17.9.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code A4595 billed for date of service November 1, 
2022. 
 
You asked the Plan to pay for procedure code A4595. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the billed code is statutorily excluded. 
 
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 A4595 has a Status Indicator of X on the Physician Fee Schedule. This means that 
procedure code A4595 is statutorily excluded from Medicare purposes. Based on this information, we decided 
that Medicare rules for coverage of procedure code A4595 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code A4595 billed for date of service November 1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on March 9, 2022. 
 
You asked the Plan to pay for the services. 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 services at issue were reimbursed 
by the Plan on April 13, 2022. Comparison of the two claims shows these are exact duplicates. There is no 
evidence presented to support that the billed services were provided twice on the same date. Based on this 
information, we decided that the Medicare rules for the services have not been met. Therefore, we decided that 
the Plan does not have to pay for the services provided on March 9, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99232 billed for date of service November 3, 
2022. 
 You asked the Plan to pay for procedure code 99232. The Plan denied your request. The Plan says payment for 
code 99232 is bundled into payment for code 99223. 
 
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 99232 
is a column II code to column I code 99223. 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 99232 billed for date of service November 3, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the DecisionDx-SCC test (0315U) provided on August 29, 
2022. 
 
You asked the Plan to pay for the DecisionDx-SCC test. You say that this testing is medically necessary. The 
Plan denied your request. The Plan says this testing is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that molecular diagnostic laboratory tests are subject 
to the MolDX application, assessment, and approval process. 
 We looked at the file and Medicare rules. This test is listed in the DEX database as not covered. Based on this 
information, we decided that Medicare rules for coverage of the DecisionDx-SCC test have not been met. 
Therefore, we decided that the Plan does not have to pay for the DecisionDx-SCC test (0315U) provided on 
August 29, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure. 
 
You asked the Plan to pre-approve 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 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the documentation is lacking regarding 
reasonably detailed and/or evidenced findings supportive of the spinal vertebral bodies as being the 
overwhelming primary generators of the enrollees chronic persistent pain. Moreover, the request is outside of 
the Food and Drug Administration (FDA)-approved treatment levels. There is no compelling rationale 
presented or extenuating circumstances noted to support the medical necessity of this request as an exception. Therefore, the requested Intracept procedure is 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 an Intracept procedure.