Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the thermal radiofrequency ablations (RFAs) of 
paravertebral facet joint nerve(s) (64635, 64636). 
 
You asked the Plan to pre-approve the RFAs. You say that the service is medically necessary. The Plan denied 
your request. The Plan says the service is not medically necessary. 
 The Plan follows Medicare rules. Medicare rules say that therapeutic facet join procedures require the patient to 
have had two (2) medically reasonable and necessary diagnostic facet joint procedures with each one providing 
a consistent minimum of 80% relief of primary (index) pain. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the RFAs. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found the records do not show that this patient has 
had two diagnostic MBBs, with each one providing a consistent minimum of 80% sustained relief of primary 
(index) pain. 
 
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 RFAs have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the thermal radiofrequency ablations (RFAs) of paravertebral facet joint nerve(s) (64635, 
64636).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Percutaneous Left Atrial Appendage Closure (LAAC) 
procedure. 
 
You asked the Plan to pre-approve a Percutaneous Left Atrial Appendage Closure (LAAC) procedure. You say 
that the service is medically necessary. The Plan denied your request. The Plan says the service 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 a Percutaneous Left Atrial Appendage 
Closure (LAAC) procedure. Our reviewer says that the requested service are not considered medically 
reasonable and necessary in this case. Our physician reviewer found Patient with no contraindication to full 
anti-coagulation do not benefit from Trans-catheter Left Atrial appendage Closure implantation.  
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 Percutaneous Left Atrial Appendage Closure (LAAC) procedure have not 
been met. Therefore, we decided that the Plan does not have to pre-approve a Percutaneous Left Atrial 
Appendage Closure (LAAC) procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve high-dose rate electronic brachytherapy. 
 
You asked the Plan to pre-approve high-dose rate electronic brachytherapy. You say that you are appealing 
with supporting records. The Plan denied your request. The Plan says the records do not show that the enrollee 
has undergone clinical staging, consideration for resection of the remaining lesion, or consideration of 
alternative options. 
 
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 high-dose rate electronic 
brachytherapy. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found there is no compelling reason offered for why this would 
be needed over more standard approaches of radiation delivery. There is a lack of demonstration of need for this versus traditional external beam radiation. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of high-dose rate electronic brachytherapy have not been met. Therefore, we 
decided that the Plan does not have to pre-approve high-dose rate electronic brachytherapy.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the drug testing (G0482) provided on November 21, 2022. 
 
You asked the Plan to pay for procedure code G0482. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says that the services are not supported 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 G0482 is Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs 
and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to 
gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, 
eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other 
universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and 
variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control 
material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all 
sources, includes specimen validity testing, per day; 15-21 drug class(es), including metabolite(s) if performed. 
 
We find that CPT code G0482 is supported in the medical record. Specifically, the record shows that 20 drug 
classes were tested, including Alcohol biomarkers, Amphetamines, Benzodiazepines, Buprenorphine, 
Cannabinoids-natural, Cocaine, Fentanyls, Gabapentin-non-blood, Heroin metabolite, Methadone, 
Methylenedioxyamphetamines, Methylphenidate, Opiates, Opioids and opiate analogs, Oxycodone, 
Phencyclidine, Pregabalin, Skeletal muscle relaxants, Tapentadol, and Tramadol. Based on this information, we 
decided that Medicare rules for coverage of procedure code G0482 have been met. Therefore, we decided that 
the Plan has to pay for the drug testing (G0482) provided on November 21, 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a back procedure (Basivertebral Nerve Ablation (BVN) 
(Intracept Intraosseous Nerve Ablation System) (64628, 64629). 
 
You asked the Plan to pre-approve the intracept procedure. You say that the service is medically necessary. The 
Plan denied your request. The Plan says the service 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 the intracept procedure. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the cause of back pain is unclear. 
 
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 intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a back procedure (Basivertebral Nerve Ablation (BVN) (Intracept Intraosseous 
Nerve Ablation System) (64628, 64629).
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 attest that you are at risk of being 
hospitalized because you need surgery and have not had them. You also say that you are afraid to do them, and 
have chronic illnesses. The Plan denied your request. The Plan says the criteria for eligibility have not been 
met. 
 The Plan must follow Medicare rules. Medicare rules say that, to qualify for SSBCI, an enrollee must have a 
documented chronic condition that is life threatening or significantly limits the health or function of the 
enrollee, has a high risk of hospitalization or adverse health outcomes, and requires intensive care coordination.  
 
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 an 
eligible condition that meets all the required criteria. 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 pre-approve electronic brachytherapy with field setting. 
 
You asked the Plan to pre-approve electronic brachytherapy. You say that this is medically necessary. The Plan 
denied your request. The Plan says there is insufficient long-term efficacy and safety data to support the routine 
use of electronic surface brachytherapy. 
 
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 items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there are no compelling reasons offered for why this would be needed over more 
standard approaches of radiation delivery. There is a lack of demonstration for the need for this method versus 
traditional external beam radiation.  
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 with field setting.
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 were qualified for this benefit last year 
for the utility you chose, due to your chronic medical conditions. You also say that you would like your appeal 
to be taken into consideration. The Plan denied your request. The Plan says the criteria for eligibility have not 
been met. 
 The Plan must follow Medicare rules. Medicare rules say that, to qualify for SSBCI, an enrollee must have a 
documented chronic condition that is life threatening or significantly limits the health or function of the 
enrollee, has a high risk of hospitalization or adverse health outcomes, and requires intensive care coordination.  
 
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 an 
eligible condition that meets all the required criteria. 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 the office visit provided on January 17, 2023, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the evaluation and management service. You say that you needed to be checked 
by the dermatologist due to your condition. You also say that you would like this to be covered. The Plan 
denied your request. The Plan says prior authorization was not obtained. 
 
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 provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the items/services at issue in this appeal. 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 office visit provided on January 17, 2023, by 
an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87798, 87150 and 87481 billed for date of 
service August 22, 2022. 
 
You asked the Plan to pay for procedure codes 87798, 87150 and 87481. You say that these services are 
supported in the medical records as billed. The Plan denied your request. The Plan says the payment for these 
services is included in the payment for other services provided on this date. Although these codes were 
submitted with the -59 modifier, the records provided do not support the use of this modifier. 
 
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 codes 
87798, 87150 and 87481 are column II codes to column I code 87500 and 87150; however, 87798, 87150 and 
87481 were each billed with a modifier.  
 
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 87798, 87150 and 87481. Our reviewer says 
that these services are not supported for separate billing. Our reviewer found the laboratory report does not 
include sufficient documentation to support that these services were separate and distinct from codes 87150 and 
87500. Therefore, these services cannot be verified as separate procedures and the use of the 59 modifier 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 procedure codes 87798, 87150 and 87481 have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure codes 87798, 87150 and 87481 billed for date of 
service August 22, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 0245U billed for date of service May 31, 
2022. 
 
You asked the Plan to pay for procedure code 0245U. You say that this service was reported appropriately. 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 May 31, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued use of a home ventilator (E0466). 
 
You asked the Plan to pre-approve the home ventilator. The Plan denied your request. The Plan says this is not 
medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a ventilator is covered for the indications established 
in the applicable LCD. 
 
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 home ventilator. Our reviewer says 
that continued use of a home ventilator is not medically reasonable and necessary in this case. Our physician 
reviewer found that the enrollee has severe obesity and obesity hypoventilation syndrome, as well has an 
elevated right hemidiaphragm. Pulmonary function testing in the past has shown severe restrictive lung disease. 
There is no diagnosis of chronic obstructive pulmonary disease (COPD), neuromuscular disease, or thoracic 
restrictive disease.  The enrollee has had a home ventilator since 2020, following a hospitalization. There is no 
demonstrated failure of BiPAP at home. Medicare does not cover a home ventilator for the treatment of obesity 
hypoventilation syndrome, or when used at settings that can be provided with BiPAP. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve continued use of a home ventilator (E0466).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable controller with harness and electronic 
connection and power seat elevation system for a power wheelchair (PWC). 
 
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 records show the enrollee has 
adequate strength in the upper extremities to manage multiple power drive controls. The requested expandable 
controller with harness and electronic connection are not medically necessary because they exceed the 
enrollee's 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 these services have not been met.  
 
The rules say that a power seat elevation feature (E2300) and power standing feature (E2301) are non-covered 
because they are not primarily medical in nature. 
 
The requested power seat elevation system is not covered because it does not serve a purpose that is primarily 
medical in nature. 
 
Therefore, we decided that the Plan does not have to pre-approve an expandable controller with harness and 
electronic connection and power seat elevation system for a power wheelchair (PWC).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 73564 billed for January 9, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure code 73564 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 73564 is radiologic examination, knee; complete, 4 or 
more views. 

We find that CPT code 73564 is not supported in the medical record. Specifically, there is no documentation of 
a complete knee x-ray of 4 or more views. 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 
procedure code 73564 billed for January 9, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve all lower extremity prostheses, flex-walk system or 
equal (L5981) and all lower extremity prostheses, multi-axial rotation unit (L5986).  

You asked the Plan to pre-approve the K3 foot. You say that a lower-level prosthetic foot will limit the 
enrollee's ability to continue functioning at the level they are currently at as a prosthetic user. The Plan denied 
your request. The Plan says the request for prosthesis with K3 foot does not meet Medicare criteria as 
reasonable and 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 the K3 foot. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the requested L5981 foot and L5986 multi-axial rotation unit exceeds the enrollee's medical 
needs and is not medically necessary per Local Coverage Determination (LCD): Lower Limb Prostheses 
(L33787) and per Social Security Act, Section 1862 (a)1(A) and the 42 CFR 411.15(k). The treating medical 
physician provider documentation does not support that the enrollee is a K3 ambulator or that the enrollee's 
functional needs require a K3 level foot. 
 
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 K3 foot have not been met. Therefore, we decided that the Plan does not 
have to pre-approve all lower extremity prostheses, flex-walk system or equal (L5981) and all lower extremity 
prostheses, multi-axial rotation unit (L5986).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 97010 billed for date of service October 20, 
2022. 
 
You asked the Plan to pay for procedure code 97010. You say that this claim was billed with the appropriate 
modifiers to show that the treatment was done independently of the primary service. The Plan denied your 
request. The Plan says procedure code 97010 is considered bundled and not separately payable. 
 
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 97010 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 97010 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 97010 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 97010 billed for date of service October 20, 2022.