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

 
We decided that the Plan does not have to pay for code 64450-59 billed for date of service March 20, 2023. 
 
You asked the Plan to pay for code 64450-59. You say that the records show that code 64450 is separate from 
the main procedure. The Plan denied your request. The Plan says the use of the 59 modifier with code 64450 is 
not supported by the medical records. The records do not support that the service was distinct or independent 
from code 01402, so this code cannot be separately paid. In addition, code 64450 was not the correct code to 
bill for the service performed. 
 
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the 
service billed with the modifier indicates a distinct procedural service.   
 
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 code 64450-59. Our reviewer says that the 
use of the 59 modifier with code 64450 is not supported by the medical record. Our physician reviewer found 
although the procedure report documents "post op pain block", the procedure report describes an iPack procedure. Interspace between the popliteal artery and capsule of the posterior knee (IPACK) blocks are used 
to reduce pain after knee surgery.  There is a more appropriate code to report for service documented. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 64450-59 have not been met. Therefore, we decided that the Plan does not 
have to pay for code 64450-59 billed for date of service March 20, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a percutaneous transcatheter closure of the left atrial 
appendage with endocardial implant (33340). 
 
You asked the Plan to pre-approve a percutaneous transcatheter closure of the left atrial appendage with 
endocardial implant. The Plan denied your request. The Plan says based on Medicare guidelines, the 
percutaneous transcatheter closure of the left atrial appendage with endocardial implant (Watchman procedure 
33340) requested does not meet the requirements for approval. 
 
The Plan follows Medicare rules. Medicare rules say that a. LAAC devices are covered when the device has 
received FDA PMA for that devices FDA-approved indication and meet all of the conditions specified in the 
Medicare rules section of this letter. 
 
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 transcatheter closure of 
the left atrial appendage with endocardial implant. Our reviewer says that the enrollee does not meet the 
coverage criteria. Our physician reviewer found the records show that the enrollee did not have a formal, 
shared decision-making interaction with an independent non-interventional physician using an evidence-based 
decision tool on oral anti-coagulation. Our reviewer found that additionally, the reviewed notes do not show 
that the enrollee is intolerant to other classes of anticoagulants such as warfarin. 
 
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 transcatheter closure of the left atrial appendage with 
endocardial implant have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
percutaneous transcatheter closure of the left atrial appendage with endocardial implant (33340).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a genicular nerve block (64624). 
 
You asked the Plan to pre-approve the nerve block. You say that the enrollee has a history of chronic pain and 
osteoarthritis of the right knee. You say that the enrollee has tried and failed other alternative therapies 
including cortisone and gel injections, knee exercises, rest and elevation, and wraps for swelling with little to 
moderate relief. You say that medial branch blocks have provided relief for almost two weeks and two days. 
You also say that the enrollee is not able to take anti-inflammatory medications due to their medical history. 
The Plan denied your request. The Plan says this 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 nerve block. Our reviewer says that 
the requested genicular nerve block is not considered medically reasonable and necessary in this case. Our physician reviewer found this is considered experimental therapy. It is the subject of ongoing clinical trials. 
Therefore, the reviewer found that the requested genicular nerve block 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 the nerve block have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a genicular nerve block (64624).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy sessions provided on November 15, 2022, to 
November 22, 2022, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for psychotherapy sessions. You say that you are appealing the denial for procedure 
code 90837 for the dates of service November 15, 2022, and November 22, 2022. The Plan denied your 
request. The Plan says there is no medical necessity for an out-of-network provider. 
 
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 requested 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 psychotherapy sessions provided on November 15, 
2022, to November 22, 2022, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a coronary catheterization and angiogram. 
 
You asked the Plan to pre-approve the surgical services. You say that you are having persistent shortness of 
breath. You say that your pulmonologist advised you are not having lung problems. You say that this interferes 
with your activities of daily living. You also say that you need help. The Plan denied your request. The Plan 
says the records do not show that you have evidence of cardiac abnormalities contributing to your symptoms. 
The Plan also says that this 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 surgical services. Our reviewer says 
that the requested coronary catheterization and angiogram are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the provided documentation indicates you have chronic dyspnea on exertion (DOE) and atypical chest pain with normal noninvasive studies. The reviewer found that 
this does not support the need for invasive cardiac catheterization and coronary angiogram. Therefore, the 
reviewer found that the requested surgical services 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 surgical services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a coronary catheterization and angiogram.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve office visits and services (92204, 99214, 93000, 93306) 
to be provided by an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve office visits and services to be provided by an OON provider. You say that 
the services are necessary. The Plan denied your request. The Plan says your PCP does not refer to the 
requested provider.  
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 
office visits and services (92204, 99214, 93000, 93306) to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99152-59 billed for date of service February 23, 2023. 
 
You asked the Plan to pay for code 99152-59. You say that code 99152-59 is supported by the medical records. 
The Plan denied your request. The Plan says the use of the 59 modifier for code 99152 is not supported by the 
medical record. The records don't support that the service was distinct or independent from 45385, so no 
separate payment can be made. 
 
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the 
service billed with the modifier indicates a distinct procedural service.   
 
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 code 99152-59. Our reviewer says that the 
use of the 59 modifier to allow for separate payment of code 99152 is not supported by the medical record. Our 
physician reviewer found the use of code 99152 to describe the services performed is not appropriate in this 
case. The medical record describes sedation and colonoscopy with snare, and in the case there is a more appropriate code that should be reported when billing Medicare for the service described. Code G0500 should 
be used for all endoscopic procedures where moderate sedation is inherent to the procedure.  Therefore, service 
denial was appropriate in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 99152-59 have not been met. Therefore, we decided that the Plan does not 
have to pay for code 99152-59 billed for date of service February 23, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 You asked the Plan to pre-approve SNF care. You say that the enrollee is in the process of being discharged 
from the hospital and needs to be transferred to the rehabilitation facility. The Plan denied your request. The 
Plan says a SNF admission is not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing or skilled therapy on an inpatient basis in a SNF 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve destruction by neurolytic agent, genicular nerve 
branches including imaging guidance (64624). 
 
You asked the Plan to pre-approve destruction by neurolytic agent, genicular nerve branches including imaging 
guidance. You say that this is medically necessary. The Plan denied your request. The Plan says this 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 destruction by neurolytic agent, 
genicular nerve branches including imaging guidance. Our reviewer says that the requested items/services are 
not considered medically reasonable and necessary in this case. Our physician reviewer found genicular nerve 
ablation is experimental for back 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 destruction by neurolytic agent, genicular nerve branches including imaging 
guidance have not been met. Therefore, we decided that the Plan does not have to pre-approve destruction by 
neurolytic agent, genicular nerve branches including imaging guidance (64624).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services provided on March 13, 2023, by an out-
of-network (OON) provider.  
 
You asked the Plan to pay for physician services. You say that the claim was denied due to the patient does not 
have out-of-network benefits, but the Plan covers emergent/urgent care. The Plan denied your request. The 
Plan says the services are not authorized because you are a non-network provider who does not work with the 
enrollee's health Plan. 
 
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 requested 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 physician services provided on March 13, 2023, 
by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure (64628, 64629). 
 
You asked the Plan to pre-approve the Intracept procedure. You say that this is medically necessary. The Plan 
denied your request. The Plan says this 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 items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no magnetic resonance imaging showing only modic changes without facet 
degenerative joint disease or foraminal 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 (64628, 64629).
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Durolane (J7318). 
 You asked the Plan to pre-approve Durolane. You say that Durolane is a medical necessity for the enrollee. The 
Plan denied your request. The Plan says step-therapy rules for coverage of Durolane have not been 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 Durolane. Our reviewer says that 
treatment with Durolane is not medically reasonable and necessary in this case. Our physician reviewer found 
that the enrollee has not trialed a viscosupplemental treatment, such as Euflexxa, which is required by the 
Plan. Step therapy, as outlined by the Plan, requires that Euflexxa be trialed first. The provided medical 
documentation does not outline contraindications or reasons the preferred medication was not considered. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Durolane have not been met. Therefore, we decided that the Plan does not have 
to pre-approve treatment with Durolane (J7318).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device (PCD) coded E0675 and 
half leg appliance coded E0673 billed for April 26, 2023. 
 
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 the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that claims for E0675 will be denied as not 
reasonable and necessary.  
 
We looked at the file and Medicare rules. The services at issue are a PCD coded E0675. These services are 
denied by Medicare as not medically necessary. Given that the E0675 PCD is not covered, the half leg 
appliance billed with code E0673 is also not covered. Therefore, we decided that the Plan does not have to pay 
for the pneumatic compression device (PCD) coded E0675 and half leg appliance coded E0673 billed for April 
26, 2023.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the genetic testing rendered on September 22, 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 that the testing was 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 pay for these services. Our reviewer says that the 
testing was medically necessary. Our physician reviewer found the enrollee has a diagnosis of other 
myelodysplastic syndromes. She has a history of low grade follicular lymphoma that was treated with 
Rituximab, then Bendamustine and Obinutuzmnab. Genomic testing has been shown to be an important 
component in determining the prognosis of patients with follicular lymphoma, as well as inclusion eligibility 
for treatment regimens. The testing was reasonable and medically necessary for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have been met. Therefore, we decided that the Plan has to pay for 
the genetic testing rendered on September 22, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a folding wheelchair (E0143) and seat attachment 
(E0156). 
 
You asked the Plan to pre-approve a folding wheelchair a folding wheelchair. You say that the services are 
necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria 
has not been met. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that the enrollee has a wheelchair with a footrest. A wheelchair with a footrest serves the same 
purpose as a folding wheelchair a folding wheelchair. Therefore, we decided that the Plan does not have to pre-
approve a folding wheelchair (E0143) and seat attachment (E0156).