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

 
We decided that the Plan does not have to pre-approve home infusion therapy, all supplies necessary for 
restoration of catheter patency or declotting (CPT code S5517) and home infusion therapy, antibiotic, antiviral, 
or antifungal therapy; once every 24 hours; administrative services, professional pharmacy services, care 
coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem 
(S9500). 
 
You asked the Plan to pre-approve the services. You say that you would like this covered because this provider 
is the only one in the area that knows your case since it is a rare case and has been helping you. You state that 
you need this to survive and fight off the infection you have. The Plan denied your request. The Plan says the 
requested procedure codes S9500 & S5517 are not listed as covered codes under the Home Infusion Therapy 
Benefit. 
 
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 services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the requested procedure codes S9500 & S5517 are not listed as one of the codes covered under 
the Home Infusion Therapy Benefit in the Medicare Claims Processing Manual Chapter 32 - Billing 
Requirements for Special Services, Section 411.3 of 411.3 - Home Infusion Drugs: Healthcare Common 
Procedural Coding System (HCPCS) Drug Codes. The review has determined that the items/services at issue in 
this case are 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve home infusion therapy, all supplies necessary for restoration of catheter patency or 
declotting (CPT code S5517) and home infusion therapy, antibiotic, antiviral, or antifungal therapy; once every 
24 hours; administrative services, professional pharmacy services, care coordination, and all necessary supplies 
and equipment (drugs and nursing visits coded separately), per diem (S9500).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 74450 billed for date of service February 25, 
2022. 
 
You asked the Plan to pay for procedure code 74450. You say that these were separate procedures which 
should be paid. The Plan denied your request. The Plan says payment for code 74450 is bundled into payment 
for code 74420. 
 
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 74450 
is a column II code to column I code 74420 with a modifier indicator of 0. The column II code is therefore not 
payable. 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 74450 billed for date of service February 25, 2022.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 
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 step therapy requirement is not met. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has not tried and failed the 
Plan's required drug, Xgeva. The records do not support that the required drug would be contraindicated or less 
effective; therefore, Prolia 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 Prolia.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet joint injections (64490 and 64491). 
 
You asked the Plan to pre-approve facet joint injections. You say that the requested facet joint intervention is 
medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the 
requested facet joint intervention.  
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 facet joint injections. Our reviewer says 
that the enrollee does not meet criteria for the requested facet joint intervention. Our physician reviewer found 
the enrollee has a complaint of neck pain. She takes Tylenol for pain. She has not had physical therapy or other 
conservative therapy for her neck pain. A plain x-ray shows multi-level facet arthropathy. However, the 
physical exam is recorded as Neck-Normal. There is no detail as to pain on rotation, flexion, extension, lateral 
movements. There is indication of pain on palpation. No motor, sensory or reflex exam of the upper extremities 
is documented. There is inadequate documentation to support any intervention in the cervical spine. There is no 
documentation of an adequate trial of conservative therapy. The request is 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 facet joint injections have not been met. Therefore, we decided that the Plan 
does not have to pre-approve facet joint injections (64490 and 64491).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve thermal destruction of the intraosseous basivertebral 
nerve for the first 2 vertebral bodies with imaging guidance, lumbar or sacral, (Intracept procedure) (64628). 
 
You asked the Plan to pre-approve the Intracept procedure. You say that the enrollee has tried and failed 
conservative treatment without relief. As such, you strongly disagree with the decision. This procedure 
improves the quality of life of patients suffering from vertebrogenic low back pain. The Plan denied your 
request. The Plan says this procedure is experimental and investigational. There are not enough studies to show 
that the use of the Intracept Procedure is better than regular treatments for the enrollee's problem. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules also say that experimental and investigational devices are not covered. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the Intracept procedure have not been met. Therefore, we decided that the Plan does not have to 
pre-approve thermal destruction of the intraosseous basivertebral nerve for the first 2 vertebral bodies with 
imaging guidance, lumbar or sacral, (Intracept procedure) (64628).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital care (99223) provided on July 9, 2022. 
 
You asked the Plan to pay for hospital care. You say that this is supported in the records. The Plan denied your 
request. The Plan says this is included in the global surgery package of another procedure. 
 
The Plan must follow Medicare rules. Medicare rules say that modifiers were established to simplify billing for 
visits and other procedures which are furnished during the postoperative period of a surgical procedure, but 
which are not included in the payment for the surgical procedure. Modifier -24 reports an unrelated evaluation and management service by same physician during a postoperative period. The rules also say that 
physicians in the same group practice who are in the same specialty must bill and be paid as though they were a 
single physician 
 
We looked at the file and Medicare rules. The record shows that the service at issue was provided during the 
90-day postoperative period of a thromboendarterectomy provided on May 18, 2022, but this service was not 
billed with a modifier to indicate it was unrelated and payable. Based on this information, we decided that 
Medicare rules for coverage of hospital care have not been met. Therefore, we decided that the Plan does not 
have to pay for hospital care (99223) provided on July 9, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation of the sacroiliac joint. 
 
You asked the Plan to pre-approve radiofrequency ablation of the sacroiliac joint. You say that this is medically 
reasonable and necessary. The Plan denied your request. The Plan says this is not a scientifically proven 
treatment according to evidence-based peer-reviewed medical literature. 
 
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 radiofrequency ablation of the 
sacroiliac joint. Our reviewer says that the requested items/services are not considered medically reasonable 
and necessary in this case. Our physician reviewer found the requested procedure is considered an 
experimental/investigational because of the wide variation in efficacy reported in the literature. Therefore, it is 
deemed not medically reasonable and necessary at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of radiofrequency ablation of the sacroiliac joint have not been met. Therefore, we 
decided that the Plan does not have to pre-approve radiofrequency ablation of the sacroiliac joint.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pontic (D6245) and a retainer crown (D6740). 
 
You asked the Plan to pre-approve a pontic and a retainer crown. You say that these services are medically 
necessary. The Plan denied your request. The Plan says the requested dental services are not covered benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
pontic (D6245) and a retainer crown (D6740).
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 IRF care is medically necessary. The Plan denied 
your request. The Plan says that the admission to an IRF is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the documentation does not support medical necessity for admission to an IRF. 
The enrollee has no medical complexity and no acute rehabilitation nursing needs for an IRF admission. While  the enrollee would benefit from physical therapy and occupational therapy, her rehabilitation needs can be 
safely met in an alternate and low intensity setting such as in a 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: 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 enrollee has lumbar spinal stenosis 
with neurogenic claudication. The 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 this device for 
this enrollees medical condition. The services are 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.
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 enrollee is being treated for 
spondylosis without myelopathy or radiculopathy of the lumbosacral region, vertebrogenic low back pain, and 
vertebral endplate pain. There are multiple plausible pathologic sources of significant pain generation. The 
chronic back pain and the lack of objective exam findings are all non-specific to any pathologic entities. 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. The 
records do not support that the Intracept procedure is reasonable and 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.
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 IRF care is medically necessary. The Plan denied 
your request. The Plan says that the admission to an IRF is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the documentation does not support the medical necessity for admission to an 
IRF due to lack of medical complexity and lack of nursing needs. While the enrollee would benefit from  physical therapy and occupational therapy, the enrollee's rehabilitation needs can be safely provided in an 
alternate and low intensity setting such as in-home with services. 
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from May 26, 
2021, through May 31, 2021. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plans 
denial for payment. The Plan denied your request. The Plan says the acute inpatient hospital care provided was 
not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.   
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 these services. Our reviewer says that the 
documentation does not support that the criteria for inpatient payment are met in this case. Our physician 
reviewer found that the enrollee was found unresponsive and arrived at the emergency department (ED) more 
alert. The enrollee was treated with diuretics, warfarin, insulin, diet, physical therapy, and was quickly able to 
ambulate with resolved glucose and mental status soon after treatments were initiated. Due to the relatively 
unremarkable workup and quick improvement in the ED, it was not expected that the enrollee would require 
hospital services that would likely cross 2 midnights.  
 
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 pay for the acute inpatient hospital care provided from May 26, 2021, through May 31, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional chiropractic manipulative treatments. 
 
You asked the Plan to pre-approve these services. You say that the requested services are medically necessary. 
The Plan denied your request. The Plan says you do not meet criteria for coverage of the requested services. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover chiropractic maintenance 
care.  
 
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 requested services are not medically necessary. Our physician reviewer found that in this case, the record 
indicates that you have articular fixation, or a subluxation, on physical examination. The record provided does 
not indicate that further clinical improvement can reasonably be expected from continuous ongoing care and 
that the requested chiropractic treatment is supportive in nature. The elements of the coverage criteria are not 
satisfied. The requested service is not recommended. 
 
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 additional chiropractic manipulative treatments.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an oxygen accessory, flow regulator capable of positive 
inspiratory pressure (E1352). 
 
You asked the Plan to pre-approve an oxygen accessory. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the request for an oxygen tubing connector does not require an 
authorization. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. The records show that you do not require an authorization for the 
requested item. The records also show that the Plan confirmed with the DME supplier that you can contact 
them directly for the accessory needed for your current equipment rental. Based on this information, we 
decided that Medicare rules for coverage of an oxygen accessory have not been met. Therefore, we decided that 
the Plan does not have to pre-approve an oxygen accessory, flow regulator capable of positive inspiratory 
pressure (E1352).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 0245U billed for date of service June 10, 
2022. 
 
You asked the Plan to pay for procedure code 0245U. You say that this test was medically necessary. The Plan 
denied your request. The Plan says payment for code 0245U is bundled into payment for code 0018U. 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 0245U 
is a column II code to column I code 0018U. 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 0245U billed for date of service June 10, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous passive motion exercise device. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says the requested use of this device is not covered. 
 
The Plan must follow Medicare rules. The rules say that CPM devices are covered only for patients who have 
received total knee replacement surgery. 
 
You have not had total knee replacement surgery. Therefore, we decided that the Plan does not have to pre-
approve a continuous passive motion exercise device.