Persius/hicric huggingface dataset:
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pay for procedure code J3490 billed for date of service November 17, 2022. 
 
You asked the Plan to pay for the billed services. You say that the drug was a necessary part of the enrollee's 
treatment. The Plan denied your request. The Plan says that the code is included in the global surgery period for 
procedure 20610. 
 
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 J3490 is unclassified drugs. We find that CPT code J3490 
is supported in the medical record. The billed code was submitted with a national drug code that coincides with 
the drug documented in the medical records. This drug is separately payable. The Plan has not provided a 
Medicare rule that would indicate the drug should be included in the global surgery package. Based on this 
information, we decided that Medicare rules for coverage of the billed services have been met. Therefore, we 
decided that the Plan has to pay for procedure code J3490 billed for date of service November 17, 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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 30 additional physical therapy visits. 
 
You asked the Plan to pre-approve the therapy services. You say that you are in chronic pain and need therapy 
as soon as possible. The Plan denied your request. The Plan says the enrollee has achieved their maximum 
potential from therapy. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
  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 therapy services. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found that the enrollee has remained with persistent pain despite nearly 50 
visits. The enrollee is able to maintain their function with a home exercise program. Continued therapy 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 the therapy services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 30 additional physical therapy visits.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve injection(s), of diagnostic or therapeutic substance(s), 
including needle or catheter placement, interlaminar epidural or subarachnoid, lumbar, or sacral (caudal); with 
imaging guidance (62323). 
 
You asked the Plan to pre-approve injections. You say that you disagree with the denial and request 
reconsideration. The Plan denied your request. The Plan says this request was denied due to lack of failed 
conservative therapy. 
 
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 injections. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee has a history of vertebral low back issues. In 2021, the enrollee underwent a 
laminectomy at the L4-L5 level with CoFix interlaminar stabilization with posterior fusion. She now presents 
with ongoing low back pain with radicular symptoms to the buttocks. Imaging confirms the presence of nerve 
disc bulging at the level of L5-S1. She has been treated with medications including opiates. The medical 
documentation does not indicate a failure to respond to four (4) weeks of non-invasive conservative care. The 
review has determined that the enrollee does not meet criteria for approval for the requested injections. The 
epidural steroid injection 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 injections have not been met. Therefore, we decided that the Plan does not have 
to pre-approve injection(s), of diagnostic or therapeutic substance(s), including needle or catheter placement, 
interlaminar epidural or subarachnoid, lumbar, or sacral (caudal); with imaging guidance (62323).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the 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 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 clinical documentation does not specify any acute complex functional impairments/status change and the enrollee is documented as being medically stable in the home setting. Thus, 
the complexity of the enrollee's documented nursing, medical and rehabilitation needs would not be expected to 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill 
(SSBCI). 
 
You asked the Plan to pre-approve SSBCI benefits. You say that you know of various people who do not have 
any of the qualifying conditions, and they still receive this benefit. The Plan denied your request. The Plan says 
you do not meet any of the coverage criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that there is a special supplemental benefit for 
enrollees with an eligible chronic condition.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of SSBCI benefits have not been met. Specifically, we have confirmed that you do not have one of 
the eligible conditions listed in the Evidence of Coverage. Therefore, we decided that the Plan does not have to 
pre-approve special supplemental benefits for the chronically ill (SSBCI).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial hospital care (procedure code 99223) rendered on 
October 28, 2022, and October 29, 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 Current Procedural Terminology (CPT) code 99223- AI, GC (1 Unit) 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 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. Typically, 70 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 not supported by the medical records. Our reviewer found that the review has determined did not 
support the presence of a comprehensive history. CPT 99223 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pay for initial hospital care (procedure code 99223) rendered on October 28, 2022, and October 29, 
2022.
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 has chronic heart failure and needs to 
regain their strength. The Plan denied your request. The Plan says an IRF admission is not medically necessary, 
and the enrollee's needs can be met at a lower 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 enrollee does not need physician supervision 3 times a week or intensive 
therapy 3 hours a day and 5 days per week with a multidisciplinary approach in an IRF. While the enrollee may 
benefit from physical and occupational therapy the enrollee's needs can be provided in an alternate setting such 
as skilled nursing facility. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ablation for knee pain. 
 
You asked the Plan to pre-approve ablation for knee pain. You say that you have been suffering from right 
knee pain since your knee replacement several years ago, and the pain affects your everyday ability to walk and 
sleep.  The Plan denied your request. The Plan says services which lack scientific evidence regarding safety 
and efficacy are not medically reasonable or necessary for Medicare Plan enrollees. There are no unique 
clinical circumstances identified that would warrant an exception in this case. 
 
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 ablation for knee pain. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found you were being treated for chronic postprocedural pain. You presented with right 
knee pain and had diagnostic results with right genicular nerve blocks with 100% resolution lasting for most of 
the day. The right knee exam reveals scars from medial arthrotomy of the knee. The treatment plan included 
right knee genicular nerve radiofrequency ablation. However, there is limited published, large-scale, long-term 
peer-reviewed literature that shows genicular nerve radiofrequency ablation to be an effective and/or safe 
treatment for the noted pathology. Further studies are needed to corroborate whether this request is as effective 
or more effective than the standard treatments for knee pain. There is no compelling rationale presented or 
extenuating circumstances noted to support the medical necessity of this request as an exception. Therefore, the 
requested radiofrequency ablation of the genicular nerve for knee pain, in this case, is not medically reasonable 
or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of ablation for knee pain have not been met. Therefore, we decided that the Plan 
does not have to pre-approve ablation for knee pain.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a thermal destruction of intraosseous basivertebral 
nerve, including all imaging guidance; first 2 vertebral bodies, lumbar or sacral (64628). 
 
You asked the Plan to pre-approve an Intracept procedure. You say that given the previously submitted 
history, physical examination, and the radiologic findings, the Intracept Procedure is medically necessary and 
supported by strong science. The Plan denied your request. The Plan says the Intracept procedure is considered 
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 an 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 and investigational for back pain. There is 
more research needed to show 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 an Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a thermal destruction of intraosseous basivertebral nerve, including all imaging 
guidance; first 2 vertebral bodies, lumbar or sacral (64628).
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency services (99285) provided on September 30, 
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 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 use of code 99285 is 
not supported by the records provided. Our reviewer found that the documentation does not contain a 
comprehensive history and medical decision making of high complexity. There is not a complete history 
documented, and there is no discussion of differential diagnoses and possible treatment options for high risk 
problem(s) that threaten life or function. 
 
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 emergency services (99285) provided on September 30, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a dynamic adjustable elbow extension/flexion device, 
includes soft interface material (E1800). 
 
You asked the Plan to pre-approve elbow stretching device. You say that no other provider in network can 
supply the enrollee's device that is being requested. The Plan denied your request. The Plan says a static 
progressive stretch (SPS) splint device is not medically necessary. Based on review of available data, static 
progressive stretch (SPS) devices are considered to be investigational for all indications. 
 
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 elbow stretching device. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found within the available elbow literature, a few studies that have compared modalities 
(including CPM) after open contracture release have suggested that CPM may improve terminal extension but 
have not shown significant differences in terms of range of motion or pain. Per chapter 13 section 13.5.4 
Medicare integrity manual as the device is not a benefit over usual 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 elbow stretching device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a dynamic adjustable elbow extension/flexion device, includes soft interface 
material (E1800).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychotherapy services. 
 
You asked the Plan to pay for the psychotherapy services. You say that the services should be covered. The 
Plan denied your request. The Plan says Licensed Clinical Professional Counselors (LCPC) are not certified 
with Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the psychotherapy services.
Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to pay for the services described by procedure code 01402, 64450, 64447, 
and 76942. We decided that the Plan does not have to pay for the services described by procedure code 99100.  
 
You asked the Plan to pay for procedure codes 01402, 64450, 64447, 76942, and 99100 billed for date of 
service June 8, 2022.. You say that you disagree with the Plan's denial. The Plan says that codes 01402, 64450, 
64447, and 76942 will be handled as a reopen. Code 99100 is not covered. 
 
We decided that the Plan has to pay for the services described by procedure code 01402, 64450, 64447, 
and 76942.  
 
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 01402, 64450, 64447, and 76942.  
 
We also decided that the Plan does not have to pay for the services described by procedure code 99100. 
 
The Plan follows Medicare rules. Medicare rules say that providers must report services correctly. Providers 
must report services with the appropriate procedure code. 
 
We looked at the file and Medicare rules. We find that procedure code 99100 has a status indicator of B on the 
Physician Fee Schedule. This means that procedure code 99100 is not separately payable. Based on this 
information, we decided that Medicare rules for coverage of the services described by procedure code 99100 
have not been met. Therefore, we decided that the Plan does not have to pay for the services described by 
procedure code 99100. 
 
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.