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

 
We decided that the Plan does not have to pre-approve an intracept procedure (64628,64629). 
 
You asked the Plan to pre-approve an intracept procedure. You say that the service is medically necessary. The 
Plan denied your request. The Plan says this procedure is considered experimental. 
 
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 services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found this procedure is considered experimental. 
 
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 an intracept procedure (64628,64629).
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 88329 billed for date of service May 20, 2022. 
 
You asked the Plan to pay for procedure code 88329. You say that this service was reported appropriately and 
is supported in the medical record. The Plan denied your request. The Plan says that the payment for code 
88329 is included in the payment for code 88334. 
 
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, there is no evidence to show that services described by code 88334 
were provided to this enrollee on the date in question or billed by the same provider or provider group. An 
NCCI edit cannot apply unless both the column I code and column II code are billed/reported. Therefore, we 
decided that the Plan has to pay for procedure code 88329 billed for date of service May 20, 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 34 additional physical therapy visits. 
 
You asked the Plan to pre-approve 34 additional physical therapy visits. You say that the enrollee would like 
reconsideration because the services are medically necessary. The Plan denied your request. The Plan says 34 
additional physical therapy visits are not medically necessary. 
 
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 34 additional physical therapy visits. 
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 does not require the 
unique skills of a professional therapist to safely and effectively provide treatment. The services can be safely 
and effectively performed only by a therapist, 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, or deliver a program to maintain the enrollee's current condition to 
prevent or slow further deterioration. The enrollee can transition to an independent home exercise program and 
does not require the ongoing skills of a professional therapist. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 34 additional physical therapy visits. have not been met. Therefore, we decided 
that the Plan does not have to pre-approve 34 additional physical therapy visits.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes A6219, A6222, A6213 billed for date of 
service December 1, 2021. 
 You asked the Plan to pay for procedure codes A6219, A6222, A6213. You say that you disagree with the 
Plan's denial. The Plan denied your request. The Plan says procedure codes A6219, A6222, A6213 are 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 A6219, A6222, A6213 have a status indicator of P on the Physician Fee Schedule. 
These services were not provided as incident to a physician service. This means that procedure code A6219, 
A6222, A6213 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure codes A6219, A6222, A6213 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure codes A6219, A6222, A6213 billed for date of service December 1, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93010 billed for date of service August 30, 
2022. 
 
You asked the Plan to pay for procedure code 93010. You say that the services were medically necessary. The 
Plan denied your request. The Plan says payment for code 93010 is bundled into payment for code 93454.  
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 93010 
is a column II code to column I code 93454. 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 93010 billed for date of service August 30, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing services provided on August 22, 2022. 
 
You asked the Plan to pay for the lab services. You say that the testing is necessary to monitor use of 
prescriptions. The Plan denied your request. The Plan says the testing is not separately reportable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. We find that the testing described by billed code 83789 is considered 
specimen validity testing which is not separately payable. Based on this information, we decided that Medicare 
rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to 
pay for the lab testing services provided on August 22, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continued stay at the inpatient behavioral health level 
of care. 
 
You asked the Plan to pre-approve a continued stay at the inpatient behavioral health level of care. You say that 
you would like the medical records to be reviewed, and for additional dates of service to be approved. The Plan 
denied your request. The Plan says a continued stay at the inpatient behavioral health level of care for this 
admission is not medically necessary beginning February 15, 2023. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
 
 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 continued stay at the inpatient 
behavioral health level of care. Our reviewer says that the enrollee does not meet the Medicare criteria for 
continued inpatient psychiatric care. Our physician reviewer found it is not expected this enrollee will improve 
in a reasonable period of time for the dates in question as they do not have suicidal or homicidal ideation, 
auditory or visual hallucinations. The enrollee has been compliant with treatment while not showing any acute 
threats to safety. Our reviewer also found that it does not appear medically necessary and reasonable to have 
psychiatric care provided at the acute inpatient level of care rather than a lower level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a continued stay at the inpatient behavioral health level of care have not been 
met. Therefore, we decided that the Plan does not have to pre-approve a continued stay at the inpatient 
behavioral health level of care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent hospital care (99231) provided on June 5, 
2022. 
  
You asked the Plan to pay for the subsequent hospital care (99231). You say that medical records are attached. 
The Plan denied your request. The Plan says the subsequent hospital care provided on June 4, 2022, has been 
overturned. The Plan also says that medical records were not submitted to determine if the subsequent hospital 
care provided on June 5, 2022, should be paid. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the subsequent hospital care have been 
met. Therefore, we decided that the Plan does not have to pay for the subsequent hospital care (99231) 
provided on June 5, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an injection procedure for sacroiliac joint, 
anesthetic/steroid, with image guidance (fluoroscopy or CT) including arthrography when performed (27096). 
 
You asked the Plan to pre-approve a sacroiliac joint procedure. You say that you disagree with the denial. The 
Plan denied your request. The Plan says the requested procedure is supported when a previous diagnostic 
sacroiliac joint injection performed produced at least 75% pain relief for the duration of the local anesthetic 
used following the injection. 
 
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 sacroiliac joint procedure. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found according to the coverage criteria, diagnostic and therapeutic injections of 
the SI joint would not likely be performed unless conservative therapy and noninvasive treatments (i.e., rest, 
physical therapy, NSAIDs, etc.) have failed. Diagnostic blocks of a sacroiliac joint can be performed to 
determine whether it is the source of low back pain. Arthropathy (joint disease) is diagnosed through a double-
comparative local anesthetic blockade of the joint by the intra-articular injection of a small volume of local 
anesthetics of different durations of actions. A positive response should demonstrate initial pain relief greater 
than or equal to 75%, and the ability to perform previously painful maneuvers. Steroids may be injected in 
addition to the local anesthetic. In this case, there is no documentation showing the enrollee received an SI 
injection with relief outcome in/or after 2021. There is also no documentation of reproducible pain using at 
least 3 of the provocative tests, or ongoing in an exercise program. The clinical information does not meet the 
coverage criteria. The requested SI joint is not indicated 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 a sacroiliac joint procedure have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an injection procedure for sacroiliac joint, anesthetic/steroid, with image 
guidance (fluoroscopy or CT) including arthrography when performed (27096).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an arthrodesis, posterior or posterolateral technique, 
single interspace; lumbar (with lateral transverse technique, when performed) (22612). 
 
You asked the Plan to pre-approve an Aurora Zip device. You say that the device is medically necessary. The 
Plan denied your request. The Plan says unproven and not medically necessary procedures are not covered by 
Medicare due to insufficient evidence of efficacy. 
 
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 Aurora Zip device. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee was being treated for spinal stenosis of the lumbar region with 
neurogenic claudication. The enrollee presented with lower back pain radiating down her left leg that has been 
ongoing for over one year. The exam reveals slow transitions from seated to standing position. Decreased 
strength is noted in the bilateral lower extremities. Deep tendon reflexes are diminished but symmetrical. 
However, there is limited published, large-scale, long-term peer-reviewed literature that shows this requested 
interspinous device to be an effective and/or safe treatment for the noted pathology. Further studies are needed 
to demonstrate this request has beneficial outcomes compared with conventional treatment. There is no 
compelling rationale presented or extenuating circumstances noted to support the medical necessity of this 
request as an exception. Therefore, the requested a ZIP fusion at L4-5, 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 an Aurora Zip device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an arthrodesis, posterior or posterolateral technique, single interspace; lumbar 
(with lateral transverse technique, when performed) (22612).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 95822 provided on June 8, 2022. 
 
You asked the Plan to pay for procedure code 95822. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the records do not support the billed service. 
 
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 95822 is Electroencephalogram (EEG); recording in 
coma or sleep only. 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for procedure code 95822. Our reviewer says that the code billed 
is not supported. Our reviewer found the record states that the Electroencephalogram (EEG) was performed for 
monitoring cortical function and depth of anesthesia, not as a diagnostic study during sleep or coma. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of procedure code 95822 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 95822 provided on June 8, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent hospital care (99233) billed for dates of service 
August 18, 2022, to August 19, 2022. 
 
You asked the Plan to pay for subsequent hospital care. You say that the services at issue have been billed 
correctly. The Plan denied your request. The Plan says records do not support the services 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 99233 is: Subsequent hospital care, per day, for the 
evaluation and management of a patient, which requires at least 2 of these 3 key components: A detailed 
interval history; A detailed examination; Medical decision making of high complexity. Counseling and/or 
coordination of care with other physicians, other qualified health care professionals, or agencies are provided 
consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the patient is 
unstable or has developed a significant complication or a significant new problem. Typically, 35 minutes are 
spent at the bedside and on the patient's hospital floor or unit.  
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for subsequent hospital care. Our reviewer says that the reported 
procedure code does not meet criteria for payment. Our reviewer found that the subsequent hospital care 
evaluation and management code at issue requires two out of these three key components: a detailed interval 
history, a detailed examination and medical decision making of high complexity. In this case, the medical 
records submitted did not support a detailed interval history and medical decision making of high complexity. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of subsequent hospital care have not been met. Therefore, we decided that the Plan 
does not have to pay for subsequent hospital care (99233) billed for dates of service August 18, 2022, to 
August 19, 2022.
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pre-approve neuropsychological testing (96133 x4). 
 
You asked the Plan to pre-approve neuropsychological testing. You say that the service is medically necessary. 
The Plan denied your request. The Plan says that the service is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
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 neuropsychological testing. Our 
reviewer says that the requested items/services are considered medically reasonable and necessary in this case. 
Our physician reviewer found based on review the records provided, this testing is intended to diagnose and 
characterize the neurocognitive effects of medical disorders that impinge directly on or indirectly on the brain 
including detection of neurologic disease based on quantitative assessment of neurocognitive abilities, 
differential diagnosis between psychogenic and neurogenic syndromes, delineation of neurocognitive effects of 
central nervous system disorders, neurocognitive monitoring of recovery or progression of central nervous 
system disorders or assessment of neurocognitive function for the formulation of rehabilitation and/or 
management strategies among individuals with neuropsychiatric disorders. The medical plan approved 
neuropsychological testing (96132 x1) and (96133 x3) however has denied neuropsychological testing (96133 
x4) claiming that it is unclear how the testing will be different than standard clinical exam since the request did 
not include the test to be administered. A letter from the provider showed that the enrollee will be having 
people Wechsler Adult Intelligence Scale, Wechsler Memory Scale, Rate Auditory Verbal Learning Test, Brief 
Visual Spatial Memory Test, Boston Naming Test, Trail Making Test, D-KEFS and Verbal Fluency Test. 
Based on the information provided this enrollee does meet the criteria for the additional neuropsychological 
testing (96133 x4) for the evaluation. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of neuropsychological testing have been met. Therefore, we decided that the Plan 
has to pre-approve neuropsychological testing (96133 x4).  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to further pay for procedure code J0897 billed for date of service 
September 20, 2022. 
 
You asked the Plan to further pay for the billed services. You say that medical records were provided. The Plan 
denied your request. The Plan says the number of units billed exceeds the maximum allowed. 
 
The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code J0897 is 120. The MAI value for this code is 3. You billed 240 units of this 
code, exceeding the MUE. The documentation does not show that the excess units were provided or were 
medically necessary. Based on this information, we decided that Medicare rules for coverage have not been 
met. Therefore, we decided that the Plan does not have to further pay for procedure code J0897 billed for date 
of service September 20, 2022.