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

 
We decided that the Plan does not have to pay for the microdissection services coded 88381 provided on July 
14, 2021. 
 
You asked the Plan to pay for the microdissection services. You say that you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says the services are not payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 88381 is microdissection (ie, sample preparation of 
microscopically identified target); manual. 
 
 
 We find that CPT code 88381 is not supported in the medical record. Specifically, this code has a professional 
component/technical component of 1. This code was billed with place of service 21 (inpatient hospital). The 
appropriate POS code for the interpretation (or PC) is the setting where the beneficiary received the TC service. 
If the interpretation is performed in the physicians office and the patient received the technical component 
service in the provider-based outpatient hospital setting. The professional interpretation of a diagnostic test 
must be separately billed with modifier 26 by the interpreting physician. This means the claim is not payable as 
billed. Based on this information, we decided that Medicare rules for coverage of the microdissection services 
have not been met. Therefore, we decided that the Plan does not have to pay for the microdissection services 
coded 88381 provided on July 14, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on March 19, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like this claim reprocessed based 
on the medical documentation. The Plan denied your request. The Plan says this service has not been billed 
appropriately. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Medicare rules say that specimen validity testing is not covered separately. 
 
The services at issue in this case are for the purpose of specimen validity testing. Based on this information, we 
decided that Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided 
that the Plan does not have to pay for the laboratory services provided on March 19, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (82310, 83970, and 84100) provided 
on January 14, 2022. 
 
You asked the Plan to pay for codes 82310, 83970, and 84100. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as 
billed. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately 
payable. Labs should bill the facility directly for lab services as they are considered part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for 
the laboratory services (82310, 83970, and 84100) provided on January 14, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a microprocessor knee prosthesis (L5856). 
 
You asked the Plan to pre-approve a microprocessor knee prosthesis (L5856). You say that the requested 
microprocessor knee prosthesis (L5856) is medically necessary. The Plan denied your request. The Plan says 
the enrollee does not meet criteria for the requested microprocessor knee prosthesis (L5856). 
 
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 microprocessor knee prosthesis 
(L5856). Our reviewer says that the enrollee does not meet criteria for the requested microprocessor knee 
prosthesis (L5856). Our physician reviewer found based on the medical records provided there is no 
documentation that the microprocessor knee prosthesis (L5856) at issue in this case meets the Local Coverage 
Determination (LCD): Lower Limb Prostheses (L33787) criteria for medically reasonable and necessary. 
Provided records do not document that a more basic knee prosthesis is inadequate for the enrollee's needs for a 
first prosthesis after the amputation. 
 
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 microprocessor knee prosthesis (L5856) have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a microprocessor knee prosthesis (L5856).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says unproven and not medically necessary procedures are not covered by Medicare due to 
insufficient evidence of 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 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 current evidence based medical guideline and the peer-reviewed literature do not fully support the 
spinal decompression device procedure over the gold standard of lumbar laminectomy. There is a lack of 
large volume, long-term peer-reviewed outcome studies to support the use of this device for this enrollees 
medical condition. FDA indications include implantation of the Superion device at one or two adjacent lumbar 
levels in patients with moderate spinal stenosis in whom operative treatment is indicated at no more than two 
levels, from L1 to L5. This enrollee has multiple degrees of spinal stenosis, many not at FDA indicated levels 
of moderate spinal stenosis (including the planned level of implantation at L4/5). There is no discussion of scoliosis of the lumbar spine, and with no documentation of a Cobb angle. There is no discussion indicating 
that a DEXA scan has demonstrated the lack of significant osteoporosis in this patient. There is no compelling 
rationale presented or extenuating circumstances noted to support the medical necessity of this request as an 
exception. Therefore, the request for Vertiflex Superion interspinous device at L4/5 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 the device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the Vertiflex device for the enrollee.
Appeal type: Outpatient Therapies
Decision: Favorable

 
We decided that the Plan has to pre-approve 10 additional physical therapy visits. 
 
You asked the Plan to pre-approve therapy visits. You say that the services are medically necessary and are 
helping you learn how to walk. The Plan denied your request. The Plan says that based on the clinical notes 
received, your balance and strength have not significantly changed, and you are able to perform a home 
exercise program. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 therapy visits. Our reviewer says that 
the coverage criteria has been meet. Our physician reviewer found that the clinical documentation shows that 
the enrollee continues to have postural instability and has not met all therapy goals. An additional 10 physical 
therapy sessions are medically reasonable and 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 therapy visits have been met. Therefore, we decided that the Plan has to pre-
approve 10 additional physical therapy visits.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service January 19, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that you would like this claim reprocessed based 
on the records provided. The Plan denied your request. The Plan says payment for code 70450 is bundled into 
payment for code 70496. 
 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 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 70450 billed for date of service January 19, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lumbar-sacral orthosis (L0650) provided on February 3, 
2022. 
 
You asked the Plan to pay for the lumbar-sacral orthosis. You say that you would like this claim reprocessed 
based on the medical records. The Plan denied your request. The Plan says the documentation submitted did 
not sufficiently support the billed supply code. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain relevant medical records which support the medical necessity for the supplies provided in this case. Specifically, the records do not indicate the ordering provider ever discussed the need fro 
the lumbar-sacral orthosis with the enrollee. The record shows that the Plan made several attempts to obtain the 
necessary documentation without success. Therefore, we decided that the Plan does not have to pay for the 
lumbar-sacral orthosis (L0650) provided on February 3, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on January 3, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately 
payable. Labs should bill the facility directly for lab services as they are considered part of the composite rate. 
No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for 
the laboratory services provided on January 3, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on June 24, 2021, billed with 
codes 81225, 81226, and 81479. 
 
You asked the Plan to pay for the genetic testing billed. You say that you would like the Plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
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 
June 24, 2021, billed with codes 81225, 81226, and 81479.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on August 17, 2021, billed with 
codes 81162, 81206, 81235, 81292, 81295, 81298, 81301, 81317, 81321, 81402, 81194, and 81309. 
 
You asked the Plan to pay for the genetic testing billed. You say that you would like the Plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
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 17, 2021, billed with codes 81162, 81206, 81235, 81292, 81295, 81298, 81301, 81317, 81321, 81402, 
81194, and 81309.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee's chance to return home and maintain 
living at home will be significantly reduced if the opportunity to participate in an acute rehabilitation program 
is denied. The Plan denied your request. The Plan says that the enrollee does not meet the requirements for this 
admission. 
 
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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found the enrollee has complex rehabilitation needs. The criteria is met, as she has inflammatory joint disease 
of multiple joints, and requires frequent physiatry oversight to manage rehabilitation of her multiple joints and 
review her medical management. The enrollee has advanced functional loss with chronic deconditioning, prior 
to the acute illness. She will require intense focus given her obesity, fragility and medical complexity. 
 
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 been met. Therefore, we decided that the Plan has to pre-approve 
acute inpatient rehabilitation facility (IRF) admission and services.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Vertiflex device. 
 
You asked the Plan to pre-approve Vertiflex device. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the requested services are 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 Vertiflex device. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee is being treated for spinal stenosis of the lumbar region with neurogenic 
claudication. The current evidence based medical guideline and peer reviewed literature do not fully support 
the spinal decompression device procedure over the gold standard of lumbar laminectomy. There is a lack of 
large volume, long-term peer-reviewed outcome studies to support the use of this device for this enrollees 
medical condition. Therefore, the enrollee does not meet criteria for the requested services. 
 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Vertiflex device have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Vertiflex device.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service March 3, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that you would like this claim reprocessed based 
on the medical records. The Plan denied your request. The Plan says payment for code 70450 is bundled into 
payment for code 70496. 
 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 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 70450 billed for date of service March 3, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the observation care services (99225) provided on January 1, 
2022. 
 
You asked the Plan to pay for the observation care services. You say that you would like this claim reprocessed 
based on the records provided. The Plan denied your request. The Plan says this claim has not been billed with 
an appropriate primary diagnosis. 
 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 99225 is subsequent observation care, per day, for the 
evaluation and management of a patient, which requires at least 2 of these 3 key components: An expanded 
problem focused interval history; An expanded problem focused examination; Medical decision making of 
moderate 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 patient is responding inadequately to therapy or has developed a minor 
complication. Typically, 25 minutes are spent at the bedside and on the patient's hospital floor or unit. 
 
We looked at the file and Medicare rules. Specifically, this code was billed with a primary/first-listed diagnosis 
code is F07.81 (postconcussional syndrome). Certain conditions have both an underlying etiology and multiple 
body system manifestations due to the underlying etiology. For such conditions, it is required that the 
underlying condition be sequenced first followed by the manifestation. That means the primary/first-listed 
diagnosis code is incorrect for this code. Based on this information, we decided that Medicare rules for 
coverage of the observation care services have not been met. Therefore, we decided that the Plan does not have 
to pay for the observation care services (99225) provided on January 1, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the sacroiliac joint injection (64625) provided on February 1, 
2022. 
 
You asked the Plan to pay for the sacroiliac joint injection (64625). You say that the attached documentation 
supports the billed charges, and the claim should be reprocessed for payment. The Plan denied your request. 
The Plan says radiofrequency ablation used for sacroiliac joint pain is considered not medically necessary and 
investigational. 
 
  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 sacroiliac joint injection (64625). Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found this is considered experimental/ investigational due to the wide variation in 
efficacy reported in the literature. 
 
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 sacroiliac joint injection (64625) have not been met. Therefore, we decided 
that the Plan does not have to pay for the sacroiliac joint injection (64625) provided on February 1, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on January 10, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services provided are not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately 
payable. Labs should bill the facility directly for lab services as they are considered part of the composite rate. 
No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for 
the laboratory services provided on January 10, 2022.