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

 
We decided that the Plan does not have to pre-approve positron emission tomography (PET) scan of the brain. 
 
You asked the Plan to pre-approve the PET scan. You say that this is medically necessary. The Plan denied 
your request. The Plan says no rationale is provided for this request, and there is no indications as to how 
findings might impact management. 
 
The Plan follows Medicare rules. Medicare rules state that a PET scan for dementia and neurodegenerative 
diseases are only covered under certain conditions. 
 
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 PET scan. Our reviewer says that 
the service is not medically necessary. Our physician reviewer found that the enrollee is noted to have essential 
tremor, and there is concern for Parkinson's Disease. The enrollee was referred for a DaT scan. However, prior 
approval was sought for a positron emission tomography/computed tomography (PET/CT) of the brain. As the 
test ordered/referred for (different CPT code) is not related to a cognitive impairment, this would not meet the 
NCD requirements for coverage of a PET scan of the brain.  
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 PET scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve positron emission tomography (PET) scan of the brain.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve implantation of an automated implantable cardioverter 
defibrillator (ICD). 
 
You asked the Plan to pre-approve implantation of an automated ICD. 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 follows Medicare rules. Medicare rules say that ICDs are covered when specific criteria are met. 
 
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 implantation of an automated ICD. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found review of clinical 
documents does not show that the enrollee meets implant criteria for defibrillator insertion according to current 
guidelines. In the absence of such documentation, implantation of an automatic defibrillator would not be 
considered medically necessary in the management of this 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 implantation of an automated ICD have not been met. Therefore, we decided 
that the Plan does not have to pre-approve implantation of an automated implantable cardioverter defibrillator 
(ICD).
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 these services are medically necessary 
for the enrollee. The Plan denied your request. The Plan says the services the enrollee needs can be provided in 
an alternate setting. 
 
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 there are no services at the LTACH that the enrollee requires that are not already 
available and covered at the current facility. Transfer to the LTACH is not medically necessary as it would not 
be clinically advantageous. Completion of treatment at the current facility is recommended. 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided from February 
25, 2023, to March 7,2023. 
 You asked the Plan to pay for SNF care. You say that the services received are coverable under the Medicare 
Act. The Plan denied your request. The Plan says the skilled care could have been provided in an alternative 
setting. 
 
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 pay for SNF care. Our reviewer says that the 
provided SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the clinical documentation shows that the enrollee initially required minimum 
assistance with self-care and mobility tasks (unclear past level of function) without clear documentation of 
daily skilled therapy. The documentation does not support the medical necessity of daily skilled services on an 
inpatient basis in a skilled nursing facility during the time period of February 25, 2023, to March 7, 2023, as 
there is no documented level of past function and documentation does not clearly show that patient required 
skilled services daily.  
 
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 pay for skilled nursing facility (SNF) care provided from February 25, 2023, to March 7,2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implantation or replacement of carotid sinus 
baroreflex activation device; total system and procedure (0266T) and a generator, neurostimulator 
(implantable), non-rechargeable with carotid sinus baroreceptor stimulation lead(s) (C1825). 
 
You asked the Plan to pre-approve a Barostim Neo system. You say that you are requesting reconsideration. 
The Plan denied your request. The Plan says the available evidence does not show this service is effective or 
provides better health outcomes. 
 
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 Barostim Neo system. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the Barostim Neo system is an electronic pulse generator implanted underneath the 
clavicle with a lead tunneled under the skin to the carotid sinus in the neck. The pulse generator delivers 
electrical impulses, analogous to a cardiac pacemaker, to the baroreceptors of one of the carotid arteries. In 
August 2019, the Food and Drug Administration (FDA) approved the system for use in enrollees with 
refractory heart failure who remain symptomatic despite treatment with guideline-directed medical therapy, are 
New York Heart Association (NYHA) Class III, have an ejection fraction less than 35%, and are not candidates 
for bi-ventricular pacing. This was based on a clinical study demonstrating improvement in normal daily 
activities, distance walked, quality of life, and improved cardiac levels biomarker levels. There remains an 
absence of randomized, blinded clinical studies examining long-term clinical outcomes establishing the value 
of Barostim Neo in enrollee management. As a result, at this time the Barostim Neo system would not be 
considered medically reasonable and necessary in this enrollee's clinical management. 
 
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 Barostim Neo system have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an implantation or replacement of carotid sinus baroreflex activation device; total 
system and procedure (0266T) and a generator, neurostimulator (implantable), non-rechargeable with carotid 
sinus baroreceptor stimulation lead(s) (C1825).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99053 billed for date of service June 9, 2023. 

You asked the Plan to pay for procedure code 99053. You say that you disagree with the denial and have 
provided medical records for review. The Plan denied your request. The Plan says procedure code 99053 is 
considered bundled and not separately payable.  
 
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 99053 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99053 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99053 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99053 billed for date of service June 9, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve kyphoplasty (22513, 22515). 
 
You asked the Plan to pre-approve kyphoplasty. 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 follows Medicare rules. Medicare rules say that percutaneous vertebroplasty and percutaneous 
vertebral augmentation (PVA or Kyphoplasty) procedures will be considered medically reasonable and 
necessary for certain indications. 
 
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 kyphoplasty. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found there is no trial of bracing. More 
conservative measures are 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 kyphoplasty have not been met. Therefore, we decided that the Plan does not 
have to pre-approve kyphoplasty (22513, 22515).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 power wheelchair with single power option 
(tilt, legrest elevator) and accessories. 
 
You asked the Plan to pre-approve a Group 3 power wheelchair with single power option. You say that this is 
medically necessary for the enrollee. The Plan denied your request. The Plan says the enrollee does not have 
medical need for the single power option included with the requested Group 3 power wheelchair. 
 
The Plan follows Medicare rules. Medicare rules say that a Group 3 power wheelchair with single power option 
may be covered when certain criteria are met. 
 
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 Group 3 power wheelchair with single 
power option. Our reviewer says that a Group 3 power wheelchair with multiple options is not medically 
necessary. Our physician reviewer found the documentation does not support that the enrollee is at high risk for 
development of a pressure ulcer, utilizes intermittent catheterization for bladder management, or needs a power 
seating system to manage increased tone or spasticity. The enrollee has no history of prior pressure ulcer with 
prior wheelchair use and no documentation of flap surgery. Therefore, the reviewer found that the requested 
Group 3 power wheelchair with single power option is not medically reasonable or necessary. As the Group 3 
power wheelchair with single power options exceeds the enrollee's medical needs the additional accessories are 
not medically 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 a Group 3 power wheelchair with single power option have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a Group 3 power wheelchair with single 
power option (tilt, legrest elevator) and accessories.
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 you would like reconsideration based on the records submitted. The Plan denied your request. The 
Plan says the enrollee has met the rehabilitation goals for a safe transition to an alternative level of care. 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 enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. 
 
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.
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 the enrollee needs this level of care. The 
Plan denied your request. The Plan says the enrollee's needs can be managed at the current facility until they 
are more stable, for transfer to another 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 medical records do not support the need for an LTACH admission and, the enrollee's 
needs can be managed 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 long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to pay for procedure code 36556. We decided that the Plan does not have to pay 
for procedure code 99292.   

You asked the Plan to pay for procedure codes 99292 and 36556 billed for date of service April 20, 2023. You 
say that you have billed the services at issue correctly. The Plan says that the provided records do not support 
the services billed. 
 
We decided that the Plan has to pay for procedure code 36556.  
 
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 36556 is: Insertion of non-tunneled centrally inserted 
central venous catheter; age 5 years or older. 
 
We asked our coder 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 procedure code 36556. Our reviewer says 
that procedure code 36556 meets criteria for payment. Our coder reviewer found that there is a note in the case 
record that supports procedure 36556 having been performed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 36556 have been met. Therefore, we decided that the Plan has 
to pay for procedure code 36556.  
 
We also decided that the Plan does not have to pay for procedure code 99292. 
 
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 99292 is: Critical care, evaluation and management of the 
critically ill or critically injured patient; each additional 30 minutes (List separately in addition to code for 
primary service). 
 
We asked our coder 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 procedure code 99292. Our reviewer says 
that procedure code 99292 does not meet criteria for payment. Our coder reviewer found that there is no time 
statement nor what was done during critical care to support code 99292.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 99292 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 99292. 
 
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 pay for the percutaneous laminotomy/laminectomy (0275T) 
provided on April 26, 2023. 
 
You asked the Plan to pay for the percutaneous laminotomy/laminectomy. You say that this service was 
necessary and should be reprocessed for payment. The Plan denied your request. The Plan says there is 
insufficient information on this claim to pay for this service. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The 
rules say that it is mandatory to report a clinical trial number on claims for items/services provided in clinical 
trials/studies/registries, or under coverage with CED. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the percutaneous laminotomy/laminectomy have not been met. Specifically, this service was billed 
with modifier Q0 indicating that it is an investigational clinical service provided in a clinical research study 
that is in an approved clinical research study. However, no clinical trial number was reported on this claim. 
Therefore, we decided that the Plan does not have to pay for the percutaneous laminotomy/laminectomy 
(0275T) provided on April 26, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are currently in a wheelchair, and the requested 
IRF admission is imperative to your health. The Plan denied your request. The Plan says your medical and 
therapy needs could be met in a skilled nursing unit.  
 
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 do not require an 
acute rehabilitation 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, 
at an intensive rehabilitation therapy program. 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 inpatient 
rehabilitation facility. You continue to have a need for skilled therapy with ongoing safety concerns and a 
potential for functional improvement. However, the documentation does not support that you would meet 
criteria for admission to an IRF.  There is no indication that you would require skilled rehabilitation in an IRF, 
participating in rehabilitation services 15 hours a week, under the supervision of a physician with at least 3 
visits weekly to regain or maintain your functional status.  You can receive further services 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 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.