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

 
We decided that the Plan does not have to pay for an office visit (procedure code 99214) rendered on 
November 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 the medical records must support modifier 24 by indicating a separate and distinct service was 
performed unrelated to the surgery. 
 
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 99214 is "Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or 
examination and moderate level of medical decision making. When using time for code selection, 30-39 
minutes of total time is spent on the date of the encounter." 
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 report documents that the 
reason for the visit for examination for cataract post-operative. In this case modifier 24 an unrelated evaluation 
and management service by the same physician or other qualified health care professional during a post-
operative period. Medicare defines same physician as physicians in the same group practice who are of the 
same specialty is not supported, as the reason for the exam is for follow up for cataract surgery. Therefore, this 
service denied correctly. 
 
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 an office visit (procedure code 99214) rendered on November 29, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services billed with codes 36620, 93503, 76937, 93312, 
93320, and 93325 for date of service November 14, 2022. 
 
You asked the Plan to pay for codes 36620, 93503, 76937, 93312, 93320, and 93325. You say that these codes 
should be paid. The Plan denied your request. The Plan says these billed codes 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 codes 36620, 93503, 76937, 93312, 93320, and 93325 are as 
follows: 
 36620 - Arterial catheterization or cannulation for sampling, monitoring or transfusion (separate procedure); 
percutaneous. 
 
93503 - Insertion and placement of flow directed catheter (eg, Swan-Ganz) for monitoring purposes. 
 
76937 - Ultrasound guidance for vascular access requiring ultrasound evaluation of potential access sites, 
documentation of selected vessel patency, concurrent real time ultrasound visualization of vascular needle 
entry, with permanent recording and reporting (List separately in addition to code for primary procedure). 
 
93312 - Echocardiography, transesophageal, real-time with image documentation (2D) (with or without M-
mode recording); including probe placement, image acquisition, interpretation and report. 
 
93320 - Doppler echocardiography, pulsed wave and/or continuous wave with spectral display (List separately 
in addition to codes for echocardiographic imaging); complete. 
 
93325 - Doppler echocardiography color flow velocity mapping (List separately in addition to codes for 
echocardiography). 
 
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 codes 36620, 93503, 76937, 93312, 93320, and 93325. Our 
reviewer says that codes 36620, 93503, 76937, 93312, 93320, and 93325 are not supported in the medical 
record. Our reviewer found the documentation does not support that these procedures were performed. The 
documentation submitted consists of an anesthesia record and information on blood products. There is no 
operative report or documentation from the provider who billed the services in question validating that these 
procedures were actually performed as billed. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of codes 36620, 93503, 76937, 93312, 93320, and 93325 have not been met. 
Therefore, we decided that the Plan does not have to pay for the services billed with codes 36620, 93503, 
76937, 93312, 93320, and 93325 for date of service November 14, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an additional 18 physical therapy (PT) visits. 
 
You asked the Plan to pre-approve the therapy services. You say that you need more PT because your right arm 
and leg are still very weak. The Plan denied your request. The Plan says you have been approved for six visits 
to restore your function and reestablish a maintenance program. There is no medical need for continuing a 
professionally supervised maintenance program after the approved six visits.  
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. You have had prior therapy and the documentation does not reveal that you require the unique skills 
of a professional therapist to safely and effectively provide treatment, that the services can be safely and 
effectively performed only by a therapist, or by or under the supervision of a therapist.  The requested services 
are not part of a maintenance program, and the specialized skill, knowledge and judgment of a qualified 
therapist is not required to establish, design and/or deliver a program to maintain the patient's current condition 
or to prevent or slow further deterioration. You can be instructed in and transition to an independent home 
exercise program with the already approved therapy.  
 
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 an additional 18 physical therapy (PT) visits.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda, Abraxane, and Carboplatin 
 You asked the Plan to pre-approve Keytruda, Abraxane, and Carboplatin. You say that the patient requires 
these drugs. The Plan denied your request. The Plan says the enrollee has not tried and failed the preferred 
drugs, Paclitaxel or Docetaxel. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Keytruda, Abraxane, and Carboplatin. 
Our reviewer says that Keytruda, Abraxane, and Carboplatin do not meet criteria for coverage. Our physician 
reviewer found the Plan requires a trial of drug Paclitaxel or Docetaxel before they will approve the requested 
drug. In this case, the patient has not tried and failed the required drug(s). There is no documentation provided 
indicating that the Plans required drug(s) would likely be less effective and/or likely have adverse effects for 
the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Keytruda, Abraxane, and Carboplatin have not been met. Therefore, we decided 
that the Plan does not have to pre-approve Keytruda, Abraxane, and Carboplatin
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 admission to an IRF is critical for the enrollee. 
The Plan denied your request. The Plan says that these services could safely be provided in an alternate setting 
or with an alternate method of treatment at a skilled nursing facility. 
 
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 have complex nursing or rehabilitation needs. While the 
medical record supports a need for physical and/or occupational therapy, there is no documented need for 
intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is 
not a reasonable expectation that the enrollee 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 IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 2 power wheelchair (PWC) described by code 
K0823.  
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 a Group 2 PWC is covered when specific criteria 
are met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the records are unclear to support that 
the enrollee requires a power wheelchair. She does not require a Group 2 PWC, as she does not require power 
tilt or recline and does not require an alternative control system. The services are therefore 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 a Group 2 power wheelchair (PWC) described by code K0823.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous vertebral augmentation. 
 
You asked the Plan to pre-approve percutaneous vertebral augmentation. You say that this service is medically 
necessary. The Plan denied your request. The Plan says the patient does not meet coverage criteria for 
percutaneous vertebral augmentation. 
 
The Plan follows Medicare rules. Medicare rules say that percutaneous vertebral augmentation is only 
coverable for patients who have not responded to non-surgical medical management. 
 
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 percutaneous vertebral augmentation. 
Our reviewer says that percutaneous vertebral augmentation is not medically necessary in this case. Our 
physician reviewer found there is no documentation that the patient has undergone a trial of bracing, so 
additional conservative measures should be tried and failed before percutaneous vertebral augmentation is approved. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of percutaneous vertebral augmentation have not been met. Therefore, we decided 
that the Plan does not have to pre-approve percutaneous vertebral augmentation.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve thermal destruction of intraosseous basivertebral nerve, 
including all imaging guidance 
 
You asked the Plan to pre-approve thermal destruction of intraosseous basivertebral nerve, including all 
imaging guidance. You say that this treatment is medically necessary. The Plan denied your request. The Plan 
says this treatment is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that thermal destruction of intraosseous basivertebral 
nerve, including all imaging guidance is only potentially coverable in the absence of untreated radiculopathy. 
 
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 thermal destruction of intraosseous 
basivertebral nerve, including all imaging guidance. Our reviewer says that the patient does not meet criteria 
for thermal destruction of intraosseous basivertebral nerve, including all imaging guidance. Our physician 
reviewer found the records show that the patient has a diagnosis of lumbar radiculopathy, and therefore does 
not meet coverage criteria for this service. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of thermal destruction of intraosseous basivertebral nerve, including all imaging 
guidance have not been met. Therefore, we decided that the Plan does not have to pre-approve thermal 
destruction of intraosseous basivertebral nerve, including all imaging guidance
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that you need more time in the nursing home to learn 
how to walk. The Plan denied your request. The Plan says you do not meet criteria for continued SNF care. 
 
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 You do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require 
daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) setting. The 
doctor says that you have not responded to skilled therapy and no skilled nursing needs. 
 
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 continued skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Orion microprocessor knee and flex-walk system and 
axial rotation unit described by codes L5828, L5845, L5848, and L5856. 
 
You asked the Plan to pre-approve the requested type of microprocessor knee. You say that it is felt that the 
requested knee should be approved. The Plan denied your request. The Plan says there is no medical necessity 
for the requested knee as a mechanical knee would meet the enrollee's needs. 
 
The Plan follows Medicare rules. Medicare rules say that coverage of prosthetic components is described in the 
Medicare rules section of this decision. 
 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 requested type of microprocessor 
knee. Our reviewer says that the requested microprocessor knee prosthesis is not shown to meet coverage 
criteria. Our physician reviewer found the microprocessor knee is for more advanced activities. The enrollee is 
a standard level 3 ambulator and does not require the more advanced device to meet her needs per L33787. The 
record provides no specific rationale for the more advanced system. 
 
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 requested type of microprocessor knee have not been met. Therefore, we 
decided that the Plan does not have to pre-approve an Orion microprocessor knee and flex-walk system and 
axial rotation unit described by codes L5828, L5845, L5848, and L5856.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transthoracic echocardiography (TTE). 
 
You asked the Plan to pre-approve TTE. You say that you have provided medical records to support approval 
of this test. The Plan denied your request. The Plan says repeat TTE is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve TTE. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the patient is asymptomatic. The documentation at this time would not point to a change in 
status that would support the medical necessity of a repeat TTE. Clinical guidelines do not support repeating a 
TTE with no intervening change in clinical status or new signs, symptoms or physical findings. In summary, 
there is no supportive evidence for the medical necessity of repeat TTE in this patient's clinical management.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of TTE have not been met. Therefore, we decided that the Plan does not have to 
pre-approve transthoracic echocardiography (TTE).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator. 
 
You asked the Plan to pre-approve a ventilator. The Plan denied your request. The Plan says Medicare does not 
cover ventilators for the requested use. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 ventilator. Our physician reviewer 
found that the enrollee severe COPD, restrictive lung disease, and aortic stenosis.   A recent arterial blood gas showed a pulmonary hypertension (pH) of 7.36 and a partial pressure of carbon 
dioxide (PaCO2) of 58.  This enrollee may benefit from BiPAP with advanced volume-assured pressure 
support (AVAPS) during sleep. However, Medicare does not cover a home ventilator when used at settings that 
can be provided with BiPAP. Therefore, A home ventilator 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 a ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve a repeat radiofrequency ablation (RFA) of the facet joint nerves at 
spinal levels L3-L5. 
 
You asked the Plan to pre-approve the requested RFA procedure. You say that the enrollee has had excellent 
pain relief from these treatments. They should be considered medically necessary. The Plan denied your 
request. The Plan says that the number of levels of injection exceeds limitations from the LCD. 
 
The Plan follows Medicare rules. Medicare rules say that repeat RFA of the facet joints is covered when prior 
treatments provided 50% or greater pain relief for at least 6 months. More than two levels of injection may be 
covered when specific evidence is provided on appeal.  
 
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 requested RFA procedure. Our 
reviewer says that the requested RFA procedure is shown to be medically reasonable and necessary. Our 
physician reviewer found the enrollee is a female with chronic low back pain and lumbar facet joint pain. She 
had L3,4,5 radiofrequency ablation on April 1, 2020, with 80% improvement. Then, she had bilateral L3, 4, 5 
radiofrequency ablation on July 28th, 2021 with 75% improvement in low back pain. She had right L4-5 
interlaminar epidural steroid injection without benefit on November 24th, 2021. She has tried physical therapy 
and pain medication trials. The request is for repeat radiofrequency ablation of bilateral L3-5.  
 
The request meets the criteria of greater than 50% pain relief for more than 6 months. The request is 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 requested RFA procedure have not been met. Therefore, we decided that the 
Plan has to pre-approve a repeat radiofrequency ablation (RFA) of the facet joint nerves at spinal levels L3-L5.  
 
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.