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

 
We decided that the Plan does not have to pay for procedure code 99233 provided on May 20, 2022, and May 
21, 2022. 
 
You asked the Plan to pay for procedure code 99233. You say that the medical records support the billing of 
procedure code 99233 provided on May 20, 2022, and May 21, 2022.  The Plan denied your request. The Plan 
says the medical records do not support the billing of procedure code 99233 provided on May 20, 2022, and 
May 21, 2022.  
 
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 procedure code 99233. Our reviewer says that the medical 
records do not support the billing of procedure code 99233 provided on May 20, 2022, and May 21, 2022.  Our 
reviewer found the enrollee was treated on May 20, 2022, and May 21, 2022. Documentation from May 20, 
2022, included a brief history, an expanded focus examination, with plans for glucose monitoring and insulin 
drip with Humalog on sliding scale while in the hospital, but no support was made for medical decision-making 
of high complexity for this note. Also, documentation from May 21, 2022, included a brief history, an 
expanded focus examination, with plans for glucose monitoring and insulin with no changes to the plan and 
again no support was made for medical decision-making of high complexity for this note. Therefore, the code, 
99233 for each of these dates is not supported by the documentation. 
 
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 99233 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 99233 provided on May 20, 2022, and May 21, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the open bilateral sacroiliac (SI) joint fusion and I 
Factor Allograft. 
 
You asked the Plan to pre-approve the open bilateral SI joint fusion and I Factor Allograft. You say that these 
procedures are medically necessary. The Plan denied your request. The Plan says the clinical value and 
effectiveness of an open SI joint fusion in the absence of SI joint instability, fracture, or tumor and I Factor 
allograft in the setting of lumbar spinal 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 the open bilateral SI joint fusion and I 
Factor Allograft. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found that detailed documentation is not evident regarding 
imaging or radiographic evidence supporting a sacroiliitis pathology. There is no clear history of SI joint pain 
onset or failure of conservative treatment directed to the SI joint. Multiple other plausible pain generators 
including at the lumbosacral spine are evident. There are limited large-scale, long-term references showing the 
safety and efficacy of the requested surgery in this clinical setting. There is no compelling rationale presented 
or extenuating circumstances noted to support the medical necessity of this request as an exception. Therefore, 
the requested open bilateral SIJ (sacroiliac joint) fusion is not medically reasonable or necessary. 
 
There is limited published, large-scale, long-term peer-reviewed literature that shows this requested allograft 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 I-Factor allograft 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 open bilateral SI joint fusion and I Factor Allograft have not been met. 
Therefore, we decided that the Plan does not have to pre-approve the open bilateral sacroiliac (SI) joint fusion 
and I Factor Allograft.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve molecular APOE genetic testing. 
 
You asked the Plan to pre-approve molecular APOE genetic testing. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the requested services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that APOE genetic tests are unlikely to impact 
therapeutic decision-making, directly impact treatment, outcome and/or clinical management in the care of the 
beneficiary and will be denied as not medically necessary. 
 
We looked at the file and Medicare rules. Review of the file shows that the services at issue are for APOE 
genetic testing. This testing is specifically not covered. Based on this information, we decided that Medicare 
rules for coverage of molecular APOE genetic testing have not been met. Therefore, we decided that the Plan 
does not have to pre-approve molecular APOE genetic testing.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 38792 provided on April 26, 2023. 
 
You asked the Plan to pay for procedure code 38792. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says that the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 38792 
is a column II code to column I code 38900; however, 38792 was billed with an appropriate modifier to bypass 
the edit. 
 
We find that procedure code 38792 is supported in the medical record. Although, injections were given in the 
same area, these are two separate chemicals, as one is a nonradioactive dye, and the second one is a radioactive 
tracer.  No documentation was found to support CPT 38792 cannot be performed at the same time as CPT 
38900 and billed separately. In this case the surgeon has performed both procedures, and therefore should be 
reported separately. Therefore, we decided that the Plan has to pay for procedure code 38792 provided on April 
26, 2023.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient hospital visits provided on April 27, 2022.  
 
You asked the Plan to pay for the outpatient hospital visits. You say that it is felt that these services should be 
reimbursed. The Plan denied your request. The Plan says the claim was not billed correctly and cannot be paid.  
 
The Plan must follow Medicare rules. Medicare rules say that hospitals must report condition code G0 on 
claims where two outpatient visits were provided on the same date.  
 
We looked at the file and Medicare rules. The claims at issue do not include condition code G0 and report two 
visits on the same date. Based on this information, we decided that Medicare rules for coverage of the 
outpatient hospital visits have not been met. Therefore, we decided that the Plan does not have to pay for the 
outpatient hospital visits provided on April 27, 2022.
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 would benefit from an acute inpatient 
comprehensive rehabilitation program to address functional impairments including transfers, ambulation, 
ADLs. The Plan denied your request. The Plan says the enrollee's records do not show the need for an intensive 
team for care. The Plan says that the services needed may be provided safely in a lower level of car  
 
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 does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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 the Vertiflex device (22869). 
 
You asked the Plan to pre-approve the Vertiflex device. You say that this 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 the Vertiflex device. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the Vertiflex device is 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 the Vertiflex device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Vertiflex device (22869).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that admission is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the enrollee can remain in the current acute care location 
until such time no further acute level care is needed. The Plan says that the services needed may be provided 
safely in a lower level of care. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee is receiving appropriate care in current acute care setting as provided by 
the Plan. Documentation does not support that LTACH services are medically appropriate 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure (64628, 64629 x2). 
 
You asked the Plan to pre-approve the Intracept procedure. You say that the request is medically necessary. 
The Plan denied your request. The Plan says the request 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 are multiple plausible pathologic sources of significant pain generation. 
The non-radiating back pain, the noted pain-aggravating factors (prolonged standing, sitting, bending forward, 
and lifting), and intact neurologic exam are all non-specific to any pathologic entities. Overall, the 
documentation is lacking regarding reasonably detailed and/or evidenced findings supportive of the spinal 
vertebral bodies as being the overwhelming primary generators of the enrollees chronic persistent pain. The 
documentation does not support actual formal surgical ablation of pre-designated basivertebral nerves as being 
medically necessary and/or reasonable at this time. There is no compelling rationale presented or extenuating 
circumstances noted to support the medical necessity of this request as an exception. 
 
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 x2).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a semi-electric hospital bed (E0261) and dry pressure 
mattress (E0184). 
 
You asked the Plan to pre-approve a semi-electric hospital bed and dry pressure mattress. You say that the 
items are medically necessary. The Plan denied your request. The Plan says the items are not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered 
medically necessary when the patient: 
 
1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or 
 
2. Requires attachments which can only be attached to a hospital bed; AND 
 
3. Requires frequent changes in body position and/or has an immediate need for a change in body position. 
 
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 semi-electric hospital bed and dry 
pressure mattress. Our reviewer says that you do not need these items. Our physician reviewer found you are 
mobile, do not have a pressure ulcer, and do not require special  attachments. 
 
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 semi-electric hospital bed and dry pressure mattress have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a semi-electric hospital bed (E0261) and dry 
pressure mattress (E0184).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that admission is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the enrollee's condition does not meet the Medicare 
guidelines. The Plan says that the services needed may be provided safely in a lower level of care. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enroll medical needs are nasal cannula, is on home O2 (8L) and twice daily wet-
to-dry dressing changes, needs can be met 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675). 
 
You asked the Plan to pay for a pneumatic compression device. You say that this item was medically 
necessary. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0675 to treat peripheral arterial disease 
is not eligible for reimbursement. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device (E0675).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a telehealth visit provided on February 25, 2023, by an out-
of-network (OON) provider.  
 
You asked the Plan to pay for the visit. You say that the visit was medically necessary. The Plan denied your 
request. The Plan says there was no prior authorization or referral from the enrollee's primary care 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 a telehealth visit provided on February 25, 2023, 
by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an upgraded replacement external ambulatory infusion 
pump (E0784). 
 You asked the Plan to pre-approve an upgraded replacement external ambulatory infusion pump. You say that 
the item is medically necessary. The Plan denied your request. The Plan says the item is not medically 
necessary. 
 
The Plan follows Medicare rules. Medicare rules say that replacement may be reimbursed when a new 
physician order and/or new CMN, when required, is needed to reaffirm the medical necessity of the item.  
 
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 upgraded replacement external 
ambulatory infusion pump. Our reviewer says that the item is not medically necessary. Our physician reviewer 
found the dysfunction and wear of your current unit or the reason for upgrading the pump was not documented 
clearly by the treating physician. 
 
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 upgraded replacement external ambulatory infusion pump have not been 
met. Therefore, we decided that the Plan does not have to pre-approve an upgraded replacement external 
ambulatory infusion pump (E0784).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (52356, 52332) provided on March 1, 2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed services are 
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 52356 is "Cystourethroscopy, with ureteroscopy and/or 
pyeloscopy; with lithotripsy including insertion of indwelling ureteral stent (eg, Gibbons or double-J type)". 
The CPT Code Manual definition of code 52332 is "Cystourethroscopy, with insertion of indwelling ureteral 
stent (eg, Gibbons or double-J type)". 
 
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 use of codes 52356 
and 52332 is not supported by the records provided. Our reviewer found that for code 52356, the procedure 
report describes that the procedure was abandoned, and was unsuccessful. In this case, a more specific code 
should be reported for the service provided. For code 52332, the procedure report does not include sufficient 
documentation to verify procedure has been performed. There is a more specific code to report for documented 
service. 
 
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 the services (52356, 52332) provided on March 1, 2023.