Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an allograft (20930). 
 
You asked the Plan to pre-approve an allograft. The Plan denied your request. The Plan says the clinical value 
and effectiveness of the allograft in the setting of anterior cervical spine fusion surgery have not been 
demonstrated in the peer-reviewed literature. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve an allograft. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is limited published, large-scale, long-term peer-reviewed literature that shows the 
requested allograft to be an effective and/or safe treatment for the noted pathology.  Further studies are needed 
to corroborate that the requested allograft is better or as good as the standard treatments. Our reviewer found 
that there is no compelling rationale presented or extenuating circumstances noted to support the medical 
necessity of this request as an exception. Our physician reviewer also found that the requested allograft in the 
setting of anterior cervical spine fusion, in this case, is not medically reasonable or necessary. 
 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an allograft have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an allograft (20930).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on March 30,2022, 
through April 7, 2022, and billed with diagnosis code A41.9. 
 You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that primary 
diagnosis A41.9, sepsis, unspecified organism is supported by the records. The Plan denied your request. The 
Plan says the documentation submitted does not support primary diagnosis of A41.9. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with primary diagnosis code A41.9, sepsis, unspecified 
organism. 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 inpatient hospital services at the 
DRG originally billed. Our reviewer says that the documentation does not support the primary diagnosis of 
A41.9, sepsis, unspecified organism. Our physician reviewer found the diagnosis code A41.9 remains 
unsupported. While the member presentation warranted consideration of sepsis as the diagnosis, there was no 
provider documentation of sepsis found therefore primary diagnosis A41.9, sepsis, unspecified organism is 
inappropriate.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on March 30,2022, through April 7, 2022, and billed with diagnosis 
code A41.9.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 77062 billed for date of service August 09, 
2022. 
 
You asked the Plan to pay for procedure code 77062. You say that per your coding team, this is a valid 
procedure code on this date of service. 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 77062 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code 77062 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code 77062 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 77062 billed for date of service August 09, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continued acute inpatient psychiatric hospitalization 
beginning on November 2, 2022. 
 
You asked the Plan to pre-approve a continued acute inpatient psychiatric hospitalization. You say that you 
believe the inpatient services were medically necessary and appropriate. The Plan denied your request. The 
Plan says a continued acute inpatient psychiatric hospitalization is 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.  
 
 
 
 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 continued acute inpatient psychiatric 
hospitalization. Our reviewer says that the enrollee does not meet the Medicare criteria for continued inpatient 
psychiatric care. Our physician reviewer found it was not expected this enrollee would improve in a reasonable 
period of time as he did not have dangerousness to self or others, auditory or visual hallucinations, delusions 
and was not showing any behavioral issues. Our reviewer found the enrollee to be cooperative and compliant 
with treatment while not showing any aggressive behaviors. Our physician reviewer also found that it does not 
appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care 
rather than 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 a continued acute inpatient psychiatric hospitalization have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a continued acute inpatient psychiatric 
hospitalization beginning on November 2, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug test coded G0482 provided on August 31, 2022. 
 
You asked the Plan to pay for the drug test. 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 G0482 is drug test(s), definitive, utilizing (1) drug 
identification methods able to identify individual drugs and distinguish between structural isomers (but not 
necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, 
single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., 
alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples 
(e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-
specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and 
mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 15-21 
drug class(es), including metabolite(s) if performed. 
 We find that CPT code G0482 is not supported in the medical record. Specifically, the documentation shows 
that 7 drug classes were tested. This means the documentation does not support 15-21 drug classes were tested. 
Based on this information, we decided that Medicare rules for coverage of the drug test have not been met. 
Therefore, we decided that the Plan does not have to pay for the drug test coded G0482 provided on August 31, 
2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99053 and 99284 billed for date of service 
June 30, 2022. 
 
You asked the Plan to pay for procedure codes 99053 and 99284. You say that you disagree with the denial. 
The Plan denied your request. The Plan says procedure codes 99053 and 99284 are not covered.  
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. The rules say that pre-operative services 
are included in the global surgical package. 
 
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 has not been met.  
 
The file shows that procedure code 99284 was related to and billed on the same day as minor procedure 30903. 
Payment for code 99284 is included in the global surgical package for 30903. 
 
Therefore, we decided that the Plan does not have to pay for procedure codes 99053 and 99284 billed for date 
of service June 30, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76377 billed for date of service October 24, 
2022, 
 
You asked the Plan to pay for procedure code 76377. You say that the procedure was medically necessary. The 
Plan denied your request. The Plan says payment for code 76377 is bundled into payment for code 70547. 
 
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 76377 
is a column II code to column I code 70547 with a modifier indicator of 0. The column II code is therefore not payable. 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 76377 billed for date of service October 24, 2022,
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee is in need of inpatient rehabilitation 
level of care. The Plan denied your request. The Plan says the enrollee does not meet the Medicare criteria for 
admission to an IRF. The services the enrollee needs can continue to be provided to you in the long-term care 
facility. 
 
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 there are no complex nursing or rehabilitation needs. While the enrollee has a need 
for physical or occupational therapy, there is no documentation of a need for an intensive rehabilitation 
program. 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 IRF admission and services.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99053 billed for date of service December 
10, 2021. 
 
You asked the Plan to pay for procedure code 99053. You say that you disagree with the Plan's denial. 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 December 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99217 billed for date of service February 14, 
2022. 
 
You asked the Plan to pay for the billed services. You say that the services have been deemed payable. The 
Plan denied your request. The Plan says the claim denied correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
 We looked at the file and the rules. The enrollees claim information shows that the enrollee received 
observation care and was discharged on the same calendar date. The observation discharge, CPT code 99217, 
cannot also be reported for this scenario. Based on this information, we decided that Medicare rules for 
coverage of the billed services have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 99217 billed for date of service February 14, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on August 2, 2022, billed with 
codes 81226, 81240, 81241, 81306, 81335, 81401, and 81406. 
 
You asked the Plan to pay for the genetic testing billed. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says panel testing should be billed using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
August 2, 2022, billed with codes 81226, 81240, 81241, 81306, 81335, 81401, and 81406.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for zoledronic acid. 
 
You asked the Plan to pay for zoledronic acid. The Plan denied your request. The Plan says this is not 
medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise 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 pay for zoledronic acid. Our reviewer says that 
zoledronic acid is not medically reasonable and necessary in this case. Our physician reviewer found that the 
enrollee has a diagnosis of osteopenia. The Food and Drug Administration has not stated that the requested 
drug is indicated for the enrollee's condition. The Medicare approved drug compendia do not contain a 
supportive citation for the use of the requested drug in the enrollee's clinical situation. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of zoledronic acid have not been met. Therefore, we decided that the Plan does not 
have to pay for zoledronic acid.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on April 27, 2022, billed with 
codes 81314, 81321, and 81351. 
 
You asked the Plan to pay for the genetic testing billed. You say that the testing was medically necessary to 
treat the enrollee. The Plan denied your request. The Plan says panel testing should be billed using one CPT 
code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
April 27, 2022, billed with codes 81314, 81321, and 81351.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the drug testing services provided on August 9, 2022. 
 
You asked the Plan to pay for the testing services. You say that the medical records are sufficient for the 
services provided. The Plan denied your request. The Plan says that medical records are needed. 
 
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 80307 is presumptive drug testing, and G0480 is 
definitive drug testing of 1-7 classes. We find that CPT code 80307 and G0480 is supported in the medical 
record. The records show that the definitive drug testing was performed following a positive presumptive test.  
Based on this information, we decided that Medicare rules for coverage of the testing services have been met. 
Therefore, we decided that the Plan has to pay for the drug testing services provided on August 9, 2022.  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the unclassified drug services billed with code J3490 for July 
5, 2022. 
 
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 payment is included in the global surgical package. 
 
The Plan must follow Medicare rules. The rules say that intra-operative services are included in the global 
surgical package. 
 
We looked at the file and Medicare rules. Procedure code J3490 was related to and billed on the same day as 
minor surgical procedure 27096. Payment for code J3490 is included in the global surgical package for 27096. 
Therefore, we decided that the Plan does not have to pay for the unclassified drug services billed with code 
J3490 for July 5, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on March 7, 2022 to 
March 11, 2022, at the Diagnosis Related Group (DRG) originally billed. 
 You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. The Plan denied your 
request. The Plan says the billed DRG is not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with diagnosis code J96.01. 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 inpatient hospital services at the DRG originally billed. Our 
reviewer says that the use of diagnosis code J96.01 is not supported by the records provided. Our physician 
reviewer found that the enrollee presented to the hospital with shortness of breath. She was found to be slightly 
hypoxic and was given 1-2 liters oxygen support in the ED with benefit. She was not in acute distress on the 
low dose oxygen support and following treatment with steroids. She did not require BiPAP, ventilator support, 
or high flow oxygen support to meet the criteria for acute respiratory failure with hypoxia, based on the 
provided documentation.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on March 7, 2022 to March 11, 2022, at the Diagnosis Related Group 
(DRG) originally billed.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve miscellaneous durable medical equipment, recliner 
portion of lift chair (E1399). 
 
You asked the Plan to pre-approve recliner portion of lift chair. You say that you are appealing the denial of the 
recliner portion of a lift chair. The Plan denied your request. The Plan says the recliner feature is not an 
additional reimbursement by Medicare. 
 
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 recliner portion of lift chair have not been met. Therefore, we decided that the Plan does not have 
to pre-approve miscellaneous durable medical equipment, recliner portion of lift chair (E1399).