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

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve the Intracept procedure. You say that the Intracept procedure is medically 
necessary. The Plan denied your request. The Plan says the Intracept procedure 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 Intracept procedure is not considered medically reasonable and necessary. Our 
physician reviewer found that there is no magnetic resonance imaging (MRI) showing only Modic changes 
without facet degenerative joint disease or stenosis. The cause of pain is not clear. 
 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 the Intracept procedure.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genicular nerve radiofrequency ablation (64624 x2). 
 
You asked the Plan to pre-approve genicular nerve radiofrequency ablation. You say that this is medically 
necessary. The Plan denied your request. The Plan says the request is not medically necessary because based on 
the medical literature this procedure is considered experimental or investigational and has not been proven to 
be beneficial for the enrollee's condition. 
 
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 genicular nerve radiofrequency 
ablation. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the provided medical records and review of the current 
peer-reviewed medical literature do not document that genicular nerve radiofrequency ablations (particularly 
repeat ablations) have been shown in controlled studies in a Centers for Medicare & Medicaid Services (CMS) 
approved journal to result in long term health benefits in patients with pain due to osteoarthritis of the knee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of genicular nerve radiofrequency ablation have not been met. Therefore, we 
decided that the Plan does not have to pre-approve genicular nerve radiofrequency ablation (64624 x2).
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve the knee brace (L1833), neuromuscular stimulator (E0745), 
electrical stimulator supplies (A4595), and delivery/setup (A9901). 
 
You asked the Plan to pre-approve the knee brace, neuromuscular stimulator, electrical stimulator supplies, and 
delivery/setup. You say that the items should be covered. The Plan denied your request. The Plan says that the 
items are not covered. 
 
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. The Plan did not indicate why this was denied or supply any evidence supporting 
the denial. Therefore, we decided that the Plan has to pre-approve the knee brace (L1833), neuromuscular 
stimulator (E0745), electrical stimulator supplies (A4595), and delivery/setup (A9901).  
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an inpatient hospital stay for an approved procedure. 
 
You asked the Plan to pre-approve the acute inpatient hospital care. You say that the inpatient stay is medically 
necessary. The Plan denied your request. The Plan says the procedure can safely be provided in an outpatient 
setting. 
 
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 pre-approve the acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient payment are met in this 
case. Our physician reviewer found the record indicates that the enrollee is scheduled for Debridement Right 
Hip Heterotopic Ossification. The record provided does not indicate that the medical condition, safety, or 
health of the enrollee would be significantly and directly threatened if care was provided in an outpatient 
setting. 
 
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 acute inpatient hospital care have not been met. Therefore, we decided that 
the Plan does not have to pre-approve an inpatient hospital stay for an approved procedure.
Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to pay for procedure code 99204-25. We decided that the Plan does not have to 
pay for procedure code 93306.  
 
You asked the Plan to pay for practitioner services provided on March 14, 2023, billed with procedure codes 
93306 and 99204-25. You say that the claim is billed correctly and should be paid. The Plan says that 
documentation does not support the billed codes.  
We decided that the Plan has to pay for procedure code 99204-25.  
 
We asked our coding 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 the practitioner services provided. Our 
reviewer says that documentation supports 99204. Documentation does not support 99306. Our physician 
reviewer found that the record states that the problem addressed was a new problem with uncertain prognosis, 
which is moderate decision making. The risk included medication management, which is also moderate 
decision making. The record is missing key elements of a complete transthoracic echocardiogram, such as 
spectral and color flow doppler echocardiography. there is a more specific code for the service provided.  
 
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 practitioner services provided have been met. Therefore, we decided that the 
Plan has to pay for procedure code 99204-25.  
 
We also decided that the Plan does not have to pay for procedure code 93306. 
 
We asked our coding 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 procedure code 93306. Our reviewer says 
that Documentation supports 99204. Documentation does not support 99306. Our physician reviewer found the 
record states that the problem addressed was a new problem with uncertain prognosis, which is moderate 
decision making. The risk included medication management, which is also moderate decision making. The 
record is missing key elements of a complete transthoracic echocardiogram, such as spectral and color flow 
doppler echocardiography. there is a more specific code for the service provided.  
 
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 93306 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 93306. 
 
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 pre-approve Zolpidem. 
 
You asked the Plan to pre-approve Zolpidem. You say that the enrollee has been on this medication since 
February, and it has always been approved. The Plan denied your request. The Plan says the medication is not 
covered as a medical benefit under the Plan. 
 The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Zolpidem.  
 
Benefits for Zolpidem may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99223 billed for date of service April 28, 2023, and 
code 99233 billed for date of service April 29, 2023. 
 
You asked the Plan to pay for codes 99223 and 99233. You did not provide a specific argument with your 
appeal request. The Plan denied your request. The Plan says codes 99223 and 99233 are not supported by the 
medical record. For code 99223, the medical records do not support a high level of medical decision making or 
total time required for the code billed. For code 99233, the medical records don't support a high level of 
medical decision making or the total time required of the code 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 99223 is codes 99223 and 99233 are not supported by the 
medical record. For code 99223, the medical records do not support a high level of medical decision making or total time required for the code billed. For code 99233, the medical records don't support a high level of 
medical decision making or the total time required of the code billed. The definition of code 99233 is 
Subsequent hospital inpatient or observation care, per day, for the evaluation and management of a patient, 
which requires a medically appropriate history and/or examination and high level of medical decision 
making. When using total time on the date of the encounter for code selection, 50 minutes must be met or 
exceeded. 
 
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 99223 and 99233. Our reviewer says that codes 99223 
and 99233 are not supported by the medical record. Our reviewer found on April 28, 2023, the documentation 
does not contain a comprehensive history, comprehensive examination or medical decision making of high 
complexity.  As such, the billing of CPT 99223 is not supported. For date of service April 29, 2023, the 
documentation does not contain any interval history, and the medical decision making is not of high 
complexity.  As such, the billing of CPT 99233 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 codes 99223 and 99233 have not been met. Therefore, we decided that the Plan 
does not have to pay for code 99223 billed for date of service April 28, 2023, and code 99233 billed for date of 
service April 29, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Stelara. 
 
You asked the Plan to pre-approve Stelara. The Plan denied your request. The Plan says the requested drug is 
not being furnished by a physician. 
 
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, 
drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. 
 
In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be 
brought to the office for administration. Since the medication does not represent an expense to the physician 
and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that 
the Plan does not have to pre-approve Stelara.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a manual enema pump (A4459). 
 
You asked the Plan to pre-approve a manual enema pump. You say that the item should be covered. The Plan 
denied your request. The Plan says this is not a covered item. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pre-approve a manual enema pump (A4459).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a life alert system (A9280). 
 
You asked the Plan to pre-approve a life alert system. You say that the item is medically necessary. The Plan 
denied your request. The Plan says this is not a covered item. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a life alert system (A9280).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve non-emergency ambulance services (A0428, A0425, 
A0382) to be provided by an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve non-emergency ambulance services with an out-of-network provider. You 
say that the services are medically necessary. The Plan denied your request. The Plan says the requested 
provider is out-of-network. The services are available in-network. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
   
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
non-emergency ambulance services (A0428, A0425, A0382) to be provided by an out-of-network (OON) 
provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee's condition requires an IRF level of care. 
The Plan denied your request. The Plan says the IRF services requested do not meet the requirements for 
approval.  
 
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 the enrollee does not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical 
record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. There is not a reasonable expectation that this enrollee will be able to fully participate in 
and benefit from the intensive rehabilitation therapy program provided in an IRF. Medically necessary care can 
be provided in a different 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you have increased your endurance and feel you are 
ready for more intense rehabilitation so that you can resume your active lifestyle as quickly as possible. The 
Plan denied your request. The Plan says your condition does not meet Medicare guidelines for services in an 
IRF.  
 
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 you are medically stable and do not need medical monitoring by a physical medicine 
and rehabilitation physician with close supervision 3 times per week. You need continued physical therapy 
(PT) and occupational therapy (OT) but you do not need 3 hours a day, 5 days a week of therapies with a 
multidisciplinary approach in an IRF. You currently have no medical complexity and no acute rehabilitation 
nursing needs to warrant an admission to an IRF. While you would benefit from PT and OT, your rehabilitation 
needs can be safely provided in an alternate and low intensity setting such as in an SNF.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99223 billed for date of service April 29, 2023. 
 
You asked the Plan to pay for code 99223. You say that the medical records support the billing of code 99223. 
The Plan denied your request. The Plan says code 99223 is not supported by the medical record. The medical 
records don't support a high level of medical decision making or total time required of the code 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 99223 is Initial hospital inpatient or observation care, per 
day, for the evaluation and management of a patient, which requires a medically appropriate history and/or 
examination and high level of medical decision making. When using total time on the date of the encounter for 
code selection, 75 minutes must be met or exceeded. 
 
 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 code 99223. Our reviewer says that code 99223 is not 
supported by the medical record. Our reviewer found there is no documented review of systems.  The medical 
decision making is not of high complexity.  As such, the billing of CPT 99223 is not supported. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 99223 have not been met. Therefore, we decided that the Plan does not 
have to pay for code 99223 billed for date of service April 29, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee is unable to climb stairs without 
assistance and requires an IRF level rehabilitation care. The Plan denied your request. The Plan says the IRF 
services requested do not meet the requirements for approval.  
 
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 the complexity of the enrollee's nursing, medical and rehabilitation can be provided 
in a lower level of care and does not require an acute hospital inpatient stay with an interdisciplinary approach 
to rehabilitation care. The enrollee requires treatment by multiple therapies, including physical therapy and 
occupational therapy, but this can be provided in a lower level of care. There is documentation that there is a 
reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF, but the services required can be provided at 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.