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

 
We decided that the Plan does not have to pre-approve Zimvie PrimaGen allograft (20930).  
 
You asked the Plan to pre-approve Zimvie PrimaGen allograft. You say that your pain is affecting everyday 
life.  The Plan denied your request. The Plan says the clinical value and effectiveness of the Zimvie PrimaGen 
Allograft in the setting of a spine fusion surgery have not been demonstrated in the peer-reviewed literature.  
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Zimvie PrimaGen allograft. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found that Zimvie Primagen allograft is experimental in spine surgery. More 
research is needed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Zimvie PrimaGen allograft have not been met. Therefore, we decided that the 
Plan does not have to pre-approve Zimvie PrimaGen allograft (20930).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve conscious sedation for a facet joint injection. 
 
You asked the Plan to pre-approve conscious sedation for a facet joint injection. You say that conscious 
sedation for a facet joint injection is medically necessary. You say the procedures are quite painful and it is 
unreasonable to subject patients to these procedures without appropriate comfort measures. The Plan denied 
your request. The Plan says conscious sedation for a facet joint injection is not medically necessary.  
 
The Plan follows Medicare rules. Medicare rules say that neither conscious sedation nor monitored anesthesia 
care (MAC) is routinely necessary for intraarticular facet joint injections or medial branch blocks and are not 
routinely reimbursable. 
 
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 conscious sedation for a facet joint 
injection. Our reviewer says that the requested conscious sedation is not considered medically necessary in this 
case. Our physician reviewer found that in this case, there is no specific medical necessity documented for the use of conscious sedation for the procedure. The review has determined that the requested conscious sedation 
does not meet the Medicare coverage criteria.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of conscious sedation for a facet joint injection have not been met. Therefore, we 
decided that the Plan does not have to pre-approve conscious sedation for a facet joint injection.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87502 billed for date of service October 17, 
2022. 
 You asked the Plan to pay for procedure code 87502. The Plan denied your request. The Plan says payment for 
code 87502 is bundled into payment for code 87633. 
 
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 87502 
is a column II code to column I code 87633. 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 87502 billed for date of 
service October 17, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the needle electromyography (EMG) studies (51785) 
provided on March 15, 2023. 
 
You asked the Plan to pay for the EMG. You say that this was medically necessary for the enrollee. The Plan 
denied your request. The Plan says electromyography is not a covered benefit for intraoperative testing during spinal surgery as the necessity and reasonableness of EMG studies shortly after trauma before EMG 
abnormalities would have reasonably had time to develop has not been established. 
 
The Plan follows Medicare rules. Medicare rules say that an EMG may be covered for certain indication when 
performed with a nerve conduction study. 
 
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 the EMG. Our reviewer says that the EMG 
was not medically necessary. Our physician reviewer found the service provided were not for an 
indication/diagnosis for which such testing is covered within the applicable LCD. Therefore, the reviewer 
found that the EMG was not medically reasonable or necessary 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 the EMG have not been met. Therefore, we decided that the Plan does not have 
to pay for the needle electromyography (EMG) studies (51785) provided on March 15, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 11302 rendered on November 9, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says Current Procedural Terminology (CPT) 11302 remains 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 11302 is "Repair, complex, trunk; each additional 5 cm 
or less (List separately in addition to code for primary procedure)." 
 
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 the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the records do not support that 
complex repair of the trunk was performed. The denied code cannot be verified.  
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 11302 rendered on November 9, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee needs aggressive therapy to regain their 
strength and independence. The Plan denied your request. The Plan says criteria for admission to an IRF setting 
have not been met.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the complexity of the enrollees nursing, medical, and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the enrollee may have a need for physical 
therapy and/or occupational therapy, there is no documented need for intensive rehabilitation services. 
Medically necessary care can be provided in a different level of care. 
 
There is not a reasonable expectation that the enrollee will be able to fully participate in and benefit from the 
intensive rehabilitation therapy program provided in an IRF. 
 
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 an IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee meets Medicare criteria for admission to 
an IRF and will benefit from acute inpatient rehabilitation that cannot be accomplished at a lower level of care.  
The Plan denied your request. The Plan says admission to an IRF is not reasonable and necessary.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the complexity of the enrollees nursing, medical, and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the enrollee may have a need for physical 
therapy and/or occupational therapy, there is no documented need for intensive rehabilitation services. 
Medically necessary care can be provided in a different level of care. 
 
There is not a reasonable expectation that the enrollee will be able to fully participate in and benefit from the 
intensive rehabilitation therapy program provided in an IRF. 
 
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 an IRF admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87150 billed for date of service February 24, 
2023. 
 You asked the Plan to pay for procedure code 87150. The Plan denied your request. The Plan says payment for 
code 87150 is bundled into payment for code 87500. 
 
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 87150 
is a column II code to column I code 87500. 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 87150 billed for date of service February 24, 
2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 5 additional hours of neuropsychological testing. 
 
You asked the Plan to pre-approve an additional 5 hours of testing. You say that this is being requested to 
assisted with differential diagnosis of enrollee-reported concerns for age advanced neurocognitive and 
functional changes. You say that the enrollee's most recent cognitive screening create concern for the earliest 
stage of Alzheimer's disease and mild neurocognitive disorder/mild cognitive impairment. You also say this is 
medically necessary for the enrollee. The Plan denied your request. The Plan says there is no documentation 
why this extended testing time is medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that testing typically requires four to eight hours to 
perform, including administration and scoring. The medical record needs to support the medical necessity of 
the testing. 
 
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 additional 5 hours of testing. Our 
reviewer says that 5 additional hours of neuropsychological testing is not medically necessary. Our physician reviewer found the provided documentation does not show why additional hours for neuropsychological testing 
would be medically necessary beyond what was initially approved. 
 
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 additional 5 hours of testing have not been met. Therefore, we decided that 
the Plan does not have to pre-approve 5 additional hours of neuropsychological testing.
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 are requesting an expedited appeal for the denial 
of an IRF admission. The Plan denied your request. The Plan says criteria for admission to the acute IRF 
setting have not been met.  
 
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 needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's 
medical conditions appear improved on stable medications with no issues that appear to require a physician's 
evaluation three or more times per week in a hospital setting. The enrollee does require physical therapy and 
occupational therapy services, but the medical records provided do not support that the intensive inpatient 
rehabilitation therapy program is necessary, and that therapy at a lower level of care is not appropriate for the 
enrollee. Based on the medical records provided there is concern that the enrollee will not be able to fully 
participate in and benefit from the intensive rehabilitation therapy program provided in an inpatient 
rehabilitation facility due to their fatigue and anxiety leading to lack of participation with therapy in the acute 
hospital. The medical records do not clarify that treatment at the skilled nursing facility level is not 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 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 are requesting a fast appeal for the denial of an 
IRF admission. The Plan denied your request. The Plan says the request is not medically necessary at this time.  
 
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 needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the 
medical record supports a need for physical and/or occupational therapy, there is no documented need for 
intensive rehabilitation services. 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a subcutaneous cardiac rhythm monitor (implantable 
loop recorder [ILR]). 
 
You asked the Plan to pre-approve the ILR device. You say that this device is indicated for the enrollee's 
clinical scenario. The Plan denied your request. The Plan says the requested device is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that an ILR is used when syncope is thought to be 
cardiac-related but is too infrequent to be detected by either a HolterTM monitor or a traditional pre-symptom 
MLR. 
 
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 ILR device. Our reviewer says that 
the requested ILR device is not medically necessary. Our physician reviewer found the provided documentation 
does not indicate that the enrollee has a history of syncope. The reviewer also found that the enrollee is on 
well-tolerated full anticoagulation. Therefore, the reviewer found that the request for an ILR device 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 the ILR device have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a subcutaneous cardiac rhythm monitor (implantable loop recorder [ILR]).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve monitored anesthesia care. 
 
You asked the Plan to pre-approve monitored anesthesia care. You say that conscious sedation is medically 
necessary for this procedure to be done. You say that this procedure is quite painful and it is unreasonable to 
subject patients to these procedures without appropriate comfort measures. The Plan denied your request. The 
Plan says the requested monitored anesthesia care is not medically necessary based on the Medicare LCD. 
 
The Plan follows Medicare rules. Medicare rules say that monitored anesthesia care is usually unnecessary or 
rarely indicated for these procedures and therefore not considered medically reasonable and necessary. In 
exceptional and unique cases, documentation must clearly establish the need for such sedation in the specific 
patient.  
 
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 monitored anesthesia care. Our 
reviewer says that the requested monitored anesthesia care is not considered medically necessary. Our 
physician reviewer found that in this case, there is no specific documentation provided indicating medical necessity for monitored anesthesia care the transforaminal epidural steroid injection. The review has 
determined that the requested anesthesia services/conscious sedation does not meet Medicare coverage criteria.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of monitored anesthesia care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve monitored anesthesia care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99213 rendered on February 13, 2023. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says Current Procedural Terminology (CPT) code 99123-25 remains 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 99213 is "Office or other outpatient visit for the 
evaluation and management of an established patient, which requires a medically appropriate history and/or 
examination and low level of medical decision making. When using time for code selection, 20-29 minutes of 
total time is spent on the date of the encounter." 
 
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 the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the medical documentation does 
not support an evaluation and management was performed that was significant and separate from the procedure 
performed this day. The enrollee came into the clinic for this injection; therefore, any workup before and after 
the procedure is included with the code. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 99213 rendered on February 13, 2023.