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

 
We decided that the Plan does not have to pre-approve the Euflexxa (J7323). 
 You asked the Plan to pre-approve the Euflexxa. You say that the drug is medically necessary. The Plan denied 
your request. The Plan says the step therapy requirements 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 the Euflexxa. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found there is no indication that the enrollee has 
tried and failed the required drug(s) or that the plan's required drug(s) would likely be less effective and/or 
likely have adverse effects 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 the Euflexxa have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Euflexxa (J7323).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the radiology services (G6002, 77427). 
 
You asked the Plan to pre-approve the radiology services. You say that the services should be covered. The 
Plan denied your request. The Plan says the enrollee was in a clinical trial. 
 
The Plan must follow Medicare rules. The rules say that Original Medicare pays for the routine costs of 
qualifying clinical trials. Enrollees in a Medicare plan receive the same coverage for qualifying clinical trials as 
people enrolled in Original Medicare. The Plan must cover only the difference between the cost-sharing in 
Original Medicare and the plan cost-sharing for the same services. 
 
In this case, you asked the Plan to pre-approve the radiology services as part of a clinical trial. The Plan does 
not cover routine costs associated with qualifying clinical trials. Therefore, we decided that the Plan does not 
have to pre-approve the radiology services (G6002, 77427).
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 the service is medically necessary. The 
Plan denied your request. The Plan says the service 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 services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the cause of back pain in this patient is unclear. 
 
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: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a CT scan of the abdomen and pelvis. 
 
You asked the Plan to pre-approve a CT scan of the abdomen and pelvis. You say that the enrollee is elderly 
and requires close observation for their medical issues to assure no further medical treatment is needed. The 
Plan denied your request. The Plan says that a CT scan of the abdomen and pelvis is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
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 pre-approve a CT scan of the abdomen and pelvis. 
Our reviewer says that a CT scan of the abdomen and pelvis is medically necessary. Our physician reviewer 
found that the CT scan of July 2022 showed improvement and partial resorption, although the enrollee had a 
rectus sheath hematoma the same year. The enrollee has chronic atrial fibrillation and is on Eliquis an 
anticoagulant. Given the enrollee's prior history of rectus sheath hematoma which requires transfusion of 4 
units and their continued Eliquis therapy which is necessary for their atrial fibrillation, it is reasonable to assess 
the abdomen and pelvis for any residual fluid or hematoma. Therefore, it can provide what amounts to a 
baseline study as the anticoagulant continues to be administered. 
 
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 CT scan of the abdomen and pelvis have not been met. Therefore, we decided 
that the Plan has to pre-approve a CT scan of the abdomen and pelvis.  
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided on August 11, 2022, billed with 
codes 36561, 76937, 77001 and 99152. 
 
You asked the Plan to pay for the imaging services provided. You say that the claim was billed correctly and 
should be paid. The Plan denied your request. The Plan says documentation does not support the billed codes. 
 
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 definitions of codes 36561, 76937, 77001 and 99152 are; Insertion of 
tunneled centrally inserted central venous access device, with subcutaneous port; age 5 years or older, 
Ultrasound guidance for vascular access requiring ultrasound evaluation of potential access sites, 
documentation of selected vessel patency, concurrent real time ultrasound visualization of vascular needle 
entry, with permanent recording and reporting (List separately in addition to code for primary procedure), Fluoroscopic guidance for central venous access device placement, replacement (catheter only or complete), or 
removal (includes fluoroscopic guidance for vascular access and catheter manipulation, any necessary contrast 
injections through access site or catheter with related venography radiologic supervision and interpretation, and 
radiographic documentation of final catheter position) (List separately in addition to code for primary 
procedure), and Moderate sedation services provided by the same physician or other qualified health care 
professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence 
of an independent trained observer to assist in the monitoring of the patient's level of consciousness and 
physiological status; initial 15 minutes of intraservice time, patient age 5 years or older. 
 
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 imaging services provided. Our reviewer says that 
documentation does not support the billed codes. Our reviewer found there is no documentation of any 
procedures 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 the imaging services provided have not been met. Therefore, we decided that 
the Plan does not have to pay for imaging services provided on August 11, 2022, billed with codes 36561, 
76937, 77001 and 99152.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex device. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says this has not been shown to be safe and effective in long-term studies. 
 
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 device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that this device is experimental. 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 the device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the Vertiflex device.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided on November 2,  2022. 
 
You asked the Plan to pay for the ambulance services. You say that the medical records provided support the 
need for the ambulance transport. The Plan denied your request. The Plan says based on review of Medicare 
rules, the request for non-emergent transport by ambulance is not approved. The records do not show the 
member is bed-bound or has any acute conditions which require continuous monitoring. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
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 ambulance services. Our reviewer says 
that the ambulance transport service was not medically necessary. Our physician reviewer found the 
transportation via ambulance to the enrollee's residence upon discharge was not medically necessary.  The 
enrollee did not require the expertise of trained personnel or the equipment available only on an ambulance in 
order to effectuate a safe transport.  Transportation could have been provided by other means (stretcher van, 
wheelchair van) without endangering 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 the ambulance services have not been met. Therefore, we decided that the Plan 
does not have to pay for ambulance services provided on November 2,  2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial hospital care (procedure code 99223) rendered on June 
22, 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) code 99223 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 99223 is "Initial hospital care, per day, for the evaluation 
and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and 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 problem(s) requiring 
admission are of high severity. Typically, 70 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 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 review has determined that 
code 99223 was not supported in the medical record, as there was no comprehensive examination. 
 
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 initial hospital care (procedure code 99223) rendered on June 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for additional injection levels rendered on August 31, 2022. 
 
You asked the Plan to pay for the additional services. You say that this was medically necessary. The Plan 
denied your request. The Plan says one to two levels, either unilateral or bilateral, are allowed per session per 
spine region. 
 
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 pay for the additional services. Our reviewer says 
that the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that the guidelines have a utilization limit of two levels per session. This exceeds that level and 
therefore, only 2 levels were medically reasonable and necessary. There is no documentation of necessity for 
the extra levels. 
 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 additional services have not been met. Therefore, we decided that the Plan 
does not have to pay for additional injection levels rendered on August 31, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the polysomnography; age 6 years or older, sleep 
staging with 4 or more additional parameters of sleep, attended by a technologist (95810). 
 
You asked the Plan to pre-approve the polysomnography. You say that the service is medically necessary. The 
Plan denied your request. The Plan says an in laboratory sleep study is needed for patients with signs of 
obstructive sleep apnea (OSA) and other health conditions. The Plan states signs of OSA can include witnessed 
apneas, loud snoring, restless sleep, daytime sleepiness, or fatigue. The Plan states patients must also have 
other health conditions that may affect the results of a home sleep apnea test (HSAT). The Plan states these 
could include lung failure, heart failure, seizures, or other health problems. The Plan states the enrollee's doctor 
did not say that the enrollee has any of these health problems. The Plan states although an in lab sleep study 
was not approved, a HSAT would be approved if requested based on the enrollee's symptoms of witnessed 
apnea. 
 
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 polysomnography. Our physician 
reviewer found an attended diagnostic polysomnogram is considered not medically necessary. This enrollee 
complains of nonrestorative sleep, nightmares, snoring, and excessive daytime sleepiness. The clinician notes a 
strong suspicion for obstructive sleep apnea. There are no medical issues that would preclude a home sleep 
study, such as severe lung or heart disease. The clinician's visit note, and appeal note do not provide 
justification for the necessity of an attended polysomnogram. The denial is upheld. 
 
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 polysomnography have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the polysomnography; age 6 years or older, sleep staging with 4 or more 
additional parameters of sleep, attended by a technologist (95810).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit billed with code 99204 for date of service 
November 14, 2022. 
 
You asked the Plan to pay for procedure code 99204. 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 99204 is office or other outpatient visit for the evaluation 
and management of a new patient, which requires a medically appropriate history and/or examination and 
moderate level of medical decision making. When using time for code selection, 45-59 minutes of total time is 
spent on the date of the encounter. 
 
We find that CPT code 99204 is not supported in the medical record. Specifically, the documentation does not 
include the time spent on this service. This means 45-59 minutes of total time spent on this encounter is not 
supported. Based on this information, we decided that Medicare rules for coverage of procedure code 99204 have not been met. Therefore, we decided that the Plan does not have to pay for the office visit billed with code 
99204 for date of service November 14, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 82378 provided on December 9, 2022. 
 
You asked the Plan to pay for procedure code 82378. You say that this service was medically necessary and is 
supported in the medical record. The Plan denied your request. The Plan says this claim was not submitted with 
a diagnosis which supports the medical necessity of this service. 
 
The Plan must follow Medicare rules. Medicare rules say that there are certain diagnosis codes which support 
the medical necessity of code 82378. Any codes which are not listed are considered not medically necessary for 
code 82378. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of procedure code 82378 have not been met. Specifically, this claim was submitted with diagnosis 
codes which are not among those codes listed as medically necessary and appropriate for this service. Therefore, we decided that the Plan does not have to pay for procedure code 82378 provided on December 9, 
2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued inpatient psychiatric services. 
 
You asked the Plan to pre-approve continued services. The Plan denied your request. The Plan says continued 
services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
 Continued care beyond May 9, 2023, was requested. 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 continued services. Our physician reviewer found that the enrollee was taking his medication 
without difficulty. It was not expected this enrollee would improve in a reasonable period of time beyond the 
dates in question as he was not showing any signs of instability. It did not appear medically necessary and 
reasonable to have psychiatric care provided at the partial hospitalization level of care rather than a lower level 
of care as he did not show any comorbid condition which required 24-hour supervision. The enrollee was not a 
danger to himself or others. He was not showing any psychiatric instability including suicidal or homicidal 
ideation, and was not showing any psychosis or aggressive behaviors but was also not showing any medical 
instability or need for this intensity 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 continued services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve continued inpatient psychiatric services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a heavy-duty walker. 
 
You asked the Plan to pre-approve a heavy-duty walker. You say that you are not able to walk properly straight 
and needs support. The current rollator that was approved is too short. The Plan denied your request. The Plan 
says you do not meet the Medicare criteria for a heavy-duty walker. You must weigh more than 300 pounds. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a heavy-duty walker have not been met. The records show that you weigh 210 pounds. Medicare 
criteria says you must weigh more than 300 pounds. Therefore, we decided that the Plan does not have to pre-
approve a heavy-duty walker.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment, no transport, (A0998) 
provided on June 3, 2022. 
 
You asked the Plan to pay for the ambulance service. You say that you cannot afford to pay for this. You say 
that you are on a very thin budget. You say that if you had known this would not be covered because you were 
not transported then you would have gone. The Plan denied your request. The Plan says ambulance response 
with no transport is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on June 3, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment, no 
transport, (A0998) provided on June 3, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an emergency department visit provided on 
November 20, 2022. 
 
You asked the Plan to pay for the emergency department visit. You say that the services were medically 
necessary. The Plan denied your request. The Plan says in order for a facility to receive reimbursement for a 
Medicare member, the facility must be enrolled to participate in the Medicare program. 
 The Plan must follow Medicare rules. Medicare rules say that Medicare covers services in an emergency 
department only if the emergency clinic is affiliated with a hospital. 
 
We looked at the file and Medicare rules. The file shows that this provider is not affiliated with a hospital and 
is not CMS approved. Therefore, we decided that the Plan does not have to pay for an emergency department 
visit provided on November 20, 2022.