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

 
We decided that the Plan does not have to pre-approve occipital neurectomy. 
 
You asked the Plan to pre-approve occipital neurectomy. You say that this is needed for the enrollee's 
debilitating pain. The Plan denied your request. The Plan says this procedure is unproven and 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 occipital neurectomy. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found as summarized in Up to Date: "Occipital nerve surgical decompression may benefit 
selected patients. In a small series of 11 patients with medically refractory occipital neuralgia, decompression 
at the level of the semispinalis capitis and trapezial tunnel was associated with pain resolution in three, significant pain relief in six, and no pain improvement in two patients over a mean follow-up period of 
approximately 12 months. In another series of patients with occipital neuralgia, pain resolved in 6 of 11 
patients at six months following surgical decompression; one patient failed to get relief. However, surgical 
decompression is not a routine therapeutic measure and should be reserved for use in a tertiary care center with 
expertise in peripheral nerve neurosurgery." Provided records in this case do not document the procedure 
would be performed in a tertiary care center with expertise in peripheral nerve neurosurgery. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of occipital neurectomy have not been met. Therefore, we decided that the Plan 
does not have to pre-approve occipital neurectomy.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 97605 for date of service February 15, 2023. 
 
You asked the Plan to pay for procedure code 97605. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services billed 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 97605 is negative pressure wound therapy (eg, vacuum 
assisted drainage collection), utilizing durable medical equipment (DME), including topical application(s), 
wound assessment, and instruction(s) for ongoing care, per session; total wound(s) surface area less than or 
equal to 50 square centimeters. 
 
 
 We find that CPT code 97605 is not supported in the medical record. Specifically, the documentation does not 
support pressure wound therapy utilizing durable medical equipment. The operative report does not state 
whether the wound vacuum used was durable medical equipment to support code 97605. Based on this 
information, we decided that Medicare rules for coverage of procedure code 97605 have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure code 97605 for date of service February 
15, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connection (E2311), harness (E2313), and 
expandable controller (E2377). 
 
You asked the Plan to pre-approve an electronic connection, harness, and expandable controller. The Plan 
denied your request. The Plan says although there are three requested power options (tilt, recline and elevating 
leg rests), there is not a medical need to control these power options through the joystick 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve an electronic connection, harness, and 
expandable controller. Our reviewer says that the requested items are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the patient's function and hand/wrist grip strength support 
that the patient can operate any power options through their own switches. 
 
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 electronic connection, harness, and expandable controller have not been met. 
Therefore, we decided that the Plan does not have to pre-approve an electronic connection (E2311), harness 
(E2313), and expandable controller (E2377).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81456 billed for date of service January 30, 
2023. 
 You asked the Plan to pay for procedure code 81456. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says payment for code 81456 is bundled into payment for code 81455. 
 
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 81456 
is a column II code to column I code 81455. 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 81456 billed for date of service January 30, 
2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for technetium (A9502) provided on May 26, 2023. 
 
You asked the Plan to pay for A9502. You say that you are appealing with supporting records. The Plan denied 
your request. The Plan says this code is not reportable by a professional in a facility place of service. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code A9502 is technetium TC-99m tetrofosmin, diagnostic, 
per study dose. 
 
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 A9502. Our reviewer says that this code does not meet 
criteria for payment. Our reviewer found there is no notation of the injection being performed or the procedure 
being performed.  
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of A9502 have not been met. Therefore, we decided that the Plan does not have to 
pay for technetium (A9502) provided on May 26, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99223 billed for date of service February 3, 
2023. 
 
You asked the Plan to pay for procedure code 99223. You say that you have billed the services at issue 
correctly. The Plan denied your request. The Plan says the provided records do not support the service 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 procedure code 99223. Our reviewer says that procedure 
code 99223 does not meet criteria for payment in this case. Our reviewer found that although there was an 
appropriate history and examination, the documentation does not support a high level of decision making on 
the date of service, nor was there a documented duration of the encounter for 75 or more minutes as required. 
 
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 99223 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 99223 billed for date of service February 3, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that the enrollee needs a non-invasive ventilator 
(NIV), and it needs to be used on auto level. The Plan denied your request. The Plan says based on Medicare 
guidelines, the NIV requested does not meet the requirements for approval. 
 The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not reasonable and necessary. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a home ventilator. Our reviewer says 
that a home ventilator is not medically reasonable and necessary. Our physician reviewer found the enrollee has 
chronic respiratory failure from COPD and was admitted with COPD exacerbation which improved with 
BIPAP therapy. The enrollee has obstructive sleep apnea (OSA) but is not compliant with CPAP at home. Our 
reviewer found that the enrollee would likely benefit from BIPAP therapy nightly. The enrollee does not have 
documented support for home ventilation given the documentation provided. Our physician reviewer found that 
hence, no home ventilator is indicated. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Eylea (J0178). 
 
You asked the Plan to pre-approve Eylea. The Plan denied your request. The Plan says that this service cannot 
be approved. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Eylea. Our reviewer says that Eylea is 
medically reasonable and necessary for the enrollee. Our physician reviewer found the documentation supports 
that the enrollee has a diagnosis of Diabetic Macular Edema, which is a covered diagnosis per plan medical 
policy and FDA indications as being an effective and reasonable treatment for the enrollee's condition. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Eylea have been met. Therefore, we decided that the Plan has to pre-approve 
Eylea (J0178).  
 
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 procedure code 95957 for date of service May 8, 2023. 
 
You asked the Plan to pay for procedure code 95957. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services are not payable 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 95957 
is an add-on code and has not been billed with an appropriate primary procedure code. 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 95957 for date of service May 8, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on July 11, 2023, to July 17, 
2023, billed with procedure code 97535-GP-59. 
 
You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says documentation does not support the billed code. 
 
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 97535 is a column II code to column I code 29581; however, 97535 
was billed with a modifier.  
 
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 practitioner services provided. Our reviewer says that 
documentation does not support the billed code. Our reviewer found that the documentation does not support 
the use of 97535 as this covers self-care at home activities of daily living, meal prep, and safety measures. 
Also, this is an add on code and there no documentation to support primary 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 practitioner services provided have not been met. Therefore, we decided that 
the Plan does not have to pay for practitioner services provided on July 11, 2023, to July 17, 2023, billed with 
procedure code 97535-GP-59.
Appeal type: Outpatient Therapies
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve 10 PT sessions. We decided that the Plan does not have to pre-
approve 6 PT sessions.  You asked the Plan to pre-approve sixteen (16) physical therapy (PT) sessions. You say that the therapy visits 
are medically necessary. The Plan says that the requested PT visits are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
We decided that the Plan has to pre-approve  10 PT visits.  
 
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 therapy services. Our reviewer says 
that the services are partially medically necessary. Our physician reviewer found that the requested physical 
therapy is generally accepted as a specific and effective therapy for shoulder pain and impaired upper extremity 
strength, range of motion and function after a stroke. The enrollee recently received physical therapy for 
similar symptoms and was referred to physical therapy again for a decline in function of his left upper 
extremity and pain. He is noted to have impaired left upper extremity strength and range of motion as well as a 
decline in function in terms of performing his daily activities. He would benefit from physical therapy to 
improve his range of motion and function. 10 sessions of physical therapy are adequate to accomplish this 
given that he has recently received physical therapy. Therefore, we decided that the Plan has to pre-approve 10 
PT visits.  
 
We also decided that the Plan does not have to pre-approve  6 PT visits. 
 
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 therapy services. Our reviewer says 
that the services are partially medically necessary. Our physician reviewer found that the enrollee is noted to 
have 85 degrees of left shoulder flexion and 40 degrees of external rotation and 80 degrees of internal rotation. 
Motor strength is noted to be 3-4/5. 6 sessions of physical therapy are not medically necessary for the enrollee. 
Therefore, we decided that the Plan does not have to pre-approve  6 PT visits. 
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bronchoscopic lung reduction with insertion of 
endobronchial valves (31651, 31648, 31647, 31649). 
 
You asked the Plan to pre-approve bronchoscopic lung reduction with insertion of endobronchial valves. You 
say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been 
established. Therefore, coverage criteria have not been met. 
 
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 bronchoscopic lung reduction with 
insertion of endobronchial valves. Our reviewer says that the requested items/services are not considered 
medically reasonable and necessary in this case. Our physician reviewer found bronchoscopic lung reduction 
with insertion of endobronchial valves is not medically necessary because Medicare criteria are not met. Pulmonary function testing does not meet Medicare criteria for hyperinflation and air trapping. Pulmonary 
function testing on October 4, 2022, showed a total lung capacity of 90% of predicted and a residual volume of 
131% of predicted. Medicare requires a total lung capacity greater than 100% of predicted and residual volume 
greater than 150% of predicted, reflecting the patient selection criteria for the clinical trials of bronchoscopic 
lung reduction. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of bronchoscopic lung reduction with insertion of endobronchial valves have not 
been met. Therefore, we decided that the Plan does not have to pre-approve bronchoscopic lung reduction with 
insertion of endobronchial valves (31651, 31648, 31647, 31649).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental extractions and alveoplasty under anesthesia. 
 
You asked the Plan to pre-approve the dental services. You say that the services are necessary. The Plan denied 
your request. The Plan says your request is not a covered benefit, and you are not enrolled in the dental 
supplement. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pre-approve involve the care, treatment, filling, removal or replacement 
of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or 
paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve dental extractions and 
alveoplasty under anesthesia.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (99223) provided on February 3, 2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code is 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 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 the services. Our reviewer says that the use of code 99223 is 
not supported by the records provided. Our reviewer found that the documentation does not show high-
complexity medical decision-making for the date in question. 
 
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 (99223) provided on February 3, 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 for the enrollee to leave the SNF at this time would 
put her life at risk. The Plan denied your request. The Plan says that the SNF level of care 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 the clinical documentation does not support the medical necessity of continued daily 
skilled services on an inpatient basis in a SNF. The clinical documentation does not specify any daily skilled 
nursing needs; therefore, continued SNF services are not supported. 
 
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.