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

 
We decided that the Plan does not have to pre-approve a Vertiflex superion spacer (22870, 22869). 
 
You asked the Plan to pre-approve a Vertiflex superion spacer. You say that the services are necessary. The 
Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been 
met. 
 
The Plan must follow Medicare rules. 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 a Vertiflex superion spacer. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the Vertiflex superion spacer 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 a Vertiflex superion spacer have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a Vertiflex superion spacer (22870, 22869).
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 requested services are medically necessary. The 
Plan denied your request. The Plan says an 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 the complexity of your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not require 
treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive 
rehabilitation therapy program. Our reviewer found that 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. Our physician reviewer also found that there is not a 
reasonable expectation that you 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 95941 billed for date of service March 2, 
2023. 
 
You asked the Plan to pay for procedure code 95941. The Plan denied your request. The Plan says the billed 
code is invalid for Medicare purposes.  
 
 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 95941 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code 95941 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code 95941 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 95941 billed for date of service March 2, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99214 for date of service May 9, 2022. 
 
You asked the Plan to pay for procedure code 99214. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the service at issue was not billed with the required modifier to allow 
separate payment within the global surgery period. 
 
 
 The Plan must follow Medicare rules. Medicare rules say that many services within the postoperative period 
are considered to be included within payment for the global surgical procedure. Two exceptions to this are EM 
services unrelated to the surgical procedure, which should be billed with modifier -24, and unrelated surgical 
procedures, which should be billed with modifier -79.  
 
We looked at the file and Medicare rules. The service at issue is within the global surgery period of code 22514 
provided on May 6, 2022 We find that the service at issue may be unrelated to the surgical procedure; however, 
the required modifier to indicate this was not used. As such, the billing rules for these services have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure code 99214 for date of service 
May 9, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance transportation provided on February 25, 2023. 
 
You asked the Plan to pay for ambulance transport. You say that the billed procedure codes are correct. The 
Plan denied your request. The Plan says the enrollee was a hospital inpatient at the time of service; therefore, 
separate payment is not made for ambulance transportation. 
 The Plan must follow Medicare rules. Medicare rules say that ambulance transportation provided to a hospital 
inpatient is covered under Part A and consequently is included in the prospective payment or reimbursed as a 
reasonable cost under Part A.  
 
We looked at the file and Medicare rules. This service is included in the inpatient payment made to the 
hospital; therefore, it is not separately reimbursed. Based on this information, we decided that Medicare rules 
for coverage of ambulance transport have not been met. Therefore, we decided that the Plan does not have to 
pay for ambulance transportation provided on February 25, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor.  
You asked the Plan to pre-approve the monitor. You say that this is vital to your life. The Plan denied your 
request. The Plan says the enrollee is not receiving insulin, and has not had any documented hypoglycemic 
episodes. 
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 the monitor. Our reviewer says that the 
requested services are not medically reasonable or necessary. Our physician reviewer found that the records do 
not document that you are insulin treated. The records indicate treatment with Jardiance and Glipizide. The 
records do not document a history of problematic hypoglycemia. 
 
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 monitor have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a continuous glucose monitor.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the new patient visit provided on March 15, 2023.  
 
You asked the Plan to pay for the new patient visit. You say that this was billed correctly.  The Plan denied 
your request. The Plan says this should have been billed as an established patient visit. 
 
The Plan must follow Medicare rules. Medicare rules say that new patient visits can be billed when no medical 
services have been provided by the same specialty within the same group for 3 years.   
 
We looked at the file and Medicare rules. The same provider saw this patient and was paid for a new patient 
visit on May 5, 2021. As less than 3 years have passed, the new patient code is not supported. Based on this 
information, we decided that Medicare rules for coverage of the new patient visit have not been met. Therefore, 
we decided that the Plan does not have to pay for the new patient visit provided on March 15, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that due to the enrollee's complex medical 
needs the best course of treatment is to admit them to an LTACH. The Plan denied your request. The Plan says 
an LTACH admission is not medically necessary.  
 
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 that the enrollee is improving and only requires short-term acute care at the current 
facility until they are more stable. The enrollee does not require services at the LTACH that are not already 
available at the current facility.  
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 LTACH services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87481, 87653, 87798, and 87801 billed for 
date of service January 31, 2023. 
 You asked the Plan to pay for procedure codes 87481, 87653, 87798, and 87801. You say that you disagree 
with the Plan's denial. The Plan denied your request. The Plan says payment for codes 87481, 87653, and 
87798 is bundled into payment for code 87801. Code 87801 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, we have confirmed that codes 
87481, 87653, and 87798 are column II codes to column I code 87801. This claim has not been billed with an 
appropriate modifier to bypass the edit. We find that three units of CPT code 87801 are not supported in the 
medical record. Specifically, the medical records do not include identification and documentation of the 
organism is represented by code 87801. 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 codes 87481, 87653, 87798, and 
87801 billed for date of service January 31, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on April 11, 2023. 
 
You asked the Plan to pay for the lab services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on April 11, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 64461 and 64462 rendered on September 8, 
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 the documents received do not support that these services were distinct or independent from 
other services performed. 
 
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 the denied codes is: 
 
CPT 64461: 
 
Paravertebral block (PVB) (paraspinous block), thoracic; single injection site (includes imaging guidance, 
when performed) 
 
CPT 64462: 
 
Paravertebral block (PVB) (paraspinous block), thoracic; second and any additional injection site(s) (includes 
imaging guidance, when performed) (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 either 
denied as separate and distinct from the primary code CPT 00542. 
 
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 codes 64461 and 64462 rendered on September 8, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genicular nerve ablation (64624). 
 
You asked the Plan to pre-approve genicular nerve ablation. 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 genicular nerve ablation. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found provided medical records and review of the current peer-reviewed medical literature 
do not document that genicular nerve ablation has been shown in controlled studies in a CMS-approved journal 
to result in long term health benefits in patients with knee pain due to osteoarthritis.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of genicular nerve ablation have not been met. Therefore, we decided that the Plan 
does not have to pre-approve genicular nerve ablation (64624).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services for date of service April 9, 2023, to 
April 15, 2023. 
 
You asked the Plan to pay for the home health services. 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 if the claim is for a period of care in which there 
are no skilled home health visits in the billing period, but a policy exception that allows billing for covered 
services is documented at the home health agency, the home health agency enters condition code 54. 
 
We looked at the file and Medicare rules. Review of the file shows that the services at issue were not billed 
with an appropriate visit revenue code. In addition, condition code 54 was not included for the billed services. 
Based on this information, we decided that Medicare rules for coverage of the home health services have not 
been met. Therefore, we decided that the Plan does not have to pay for the home health services for date of 
service April 9, 2023, to April 15, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the out-of-area services rendered on February 17, 2023. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says an itemized bill was not received to show what services were paid for. 
 
Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that 
while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis and pre-approved care. The Plan contract says that proof of payment and an itemized receipt must be submitted for 
reimbursement requests.  
 
We looked at the file and the Plans rules. The file shows that you received services that were not emergent in 
nature and an itemized receipt was not submitted for the reimbursement request. The submitted receipt does not 
show each item that was purchased. Based on this information, we decided that the Plans for coverage of these 
services have not been met. Therefore, we decided that the Plan does not have to pay for the out-of-area 
services rendered on February 17, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from March 4, 2023, 
through March 24, 2023. 
 You asked the Plan to pay for the home health services. You say that an NOA was submitted timely for this 
service. The Plan denied your request. The Plan says the NOA was not received timely. As such, this final 
claim was correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
The file does not include any clear evidence that an NOA was ever received by the Plan. As more than 30 days 
passed between the timely filing date and the NOA receipt, no payment can be made on this claim. Therefore, 
we decided that the Plan does not have to pay for the home health services provided from March 4, 2023, 
through March 24, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a LinQ SI (sacroiliac) stabilization device provided February 
15, 2023. 
 
You asked the Plan to pay for a LinQ device. You say that this procedure would benefit the enrollee. The Plan 
denied your request. The Plan says The LinQ SI stabilization device remains experimental, and more research 
is needed to show safety and 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 pay for a LinQ device. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found 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. 
 
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 LinQ device have not been met. Therefore, we decided that the Plan does not 
have to pay for a LinQ SI (sacroiliac) stabilization device provided February 15, 2023.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gelsyn-3. 
 You asked the Plan to pre-approve Gelsyn-3. You say that the enrollee received an intra-articular steroid 
injection in both knees on August 28, 2023. The Plan denied your request. The Plan says that 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 Gelsyn-3. Our reviewer says that 
Gelsyn-3 is not medically necessary. Our physician reviewer found that the enrollee recently received bilateral 
knee corticosteroid injections on August 28, 2023. Also, it is too early in the treatment course to determine that 
the injections have or have not been beneficial to the enrollee. Additionally, there is no documentation of the 
failure of or contraindication to intra-articular glucocorticoid injections. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Gelsyn-3 have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Gelsyn-3.