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

 
We decided that the Plan does not have to pre-approve destruction by neurolytic agent, genicular nerve 
branches including imaging guidance, when performed (64624). 
 
You asked the Plan to pre-approve destruction by neurolytic agent, genicular nerve branches including imaging 
guidance. You say that this is medically necessary. The Plan denied your request. The Plan says this procedure 
is not considered to be the standard of care for treatment of chronic knee pain. 
 
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 destruction by neurolytic agent, 
genicular nerve branches including imaging guidance. Our reviewer says that the requested items/services are 
not considered medically reasonable and necessary in this case. Our physician reviewer found genicular nerve 
ablation is experimental for knee pain.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of destruction by neurolytic agent, genicular nerve branches including imaging 
guidance have not been met. Therefore, we decided that the Plan does not have to pre-approve destruction by 
neurolytic agent, genicular nerve branches including imaging guidance, when performed (64624).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87491 and 87640 billed for date of service 
June 26, 2023. 
 
You asked the Plan to pay for the billed services. You say that the coding is approved by Medicare. The Plan 
denied your request. The Plan says the codes 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 code. 
 
In this case, the CPT Code Manual definition of code 87491 is infectious agent detection by nucleic acid (DNA 
or RNA); Chlamydia trachomatis, amplified probe technique. We find that CPT code 87491 is not supported in 
the medical record. The records do not show that this test was included in the panel testing ordered. The 
records do not include results for this test. Based on this information, we decided that the Medicare rules for 
coverage have not been met. 
 
We have confirmed that code 87640 is a column II code to column I code 87641. The medical records do not 
show that code 87640, billed with the -59 modifier was a distinct procedural service. The records show that this 
test was included in the panel requested. 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 codes 87491 and 87640 billed for date of service June 26, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 22845 billed for date of service February 14, 
2023. 
 
You asked the Plan to pay for procedure code 22845. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says payment for code 22845 is bundled into payment for code 22853. 
 
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 22845 
is a column II code to column I code 22853. 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 22845 billed for date of service February 14, 
2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for evaluation and management services (procedure code 99223) 
rendered on May 2, 2023. 
 
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 do not support this level of care. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99223 is "Initial hospital inpatient or observation care, 
per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or 
examination and high level of medical decision making. When using total time on the date of the encounter for 
code selection, 75 minutes must be met or exceeded." 
 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 provided records in this case 
do not document 2 out of 3 of an extensive number of diagnoses or management options, an extensive amount 
and complexity of data reviewed and high risk of complication or that at least 75 minutes were spent on the 
evaluation and management on 05/02/2023.  
 
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 evaluation and management services (procedure code 99223) rendered on May 2, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ViviGen allograft (20930). 
 
You asked the Plan to pre-approve a ViviGen allograft. You say that this is medically necessary. The Plan 
denied your request. The Plan says the clinical value and effectiveness of the ViviGen Allograft in the setting 
of posterior lumbar Interbody 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 a ViviGen 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 
this requested allograft to be an effective and/or safe treatment for the noted pathology. Further studies are 
needed to demonstrate this request has beneficial outcomes compared with conventional treatment. 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 ViviGen allograft have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a ViviGen allograft (20930).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve endoscopy, wrist, surgical, with release of transverse 
carpal ligament (29848), and neuroplasty and/or transposition; median nerve at carpal tunnel (64721). 
 
You asked the Plan to pre-approve endoscopy, wrist, surgical, with release of transverse carpal ligament, and 
neuroplasty and/or transposition; median nerve at carpal tunnel. You say that this is medically necessary. The 
Plan denied your request. The Plan says this is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve endoscopy, wrist, surgical, with release 
of transverse carpal ligament, and neuroplasty and/or transposition, median nerve at carpal tunnel. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found detailed documentation regarding a trial and failure of recent, reasonable, 
comprehensive, less invasive conservative care measures is not evident. The noted conservative treatment of 
physical therapy and chiropractic treatments were not clearly documented to have been directed at the bilateral 
wrists. Additionally, there is no indication of a trial and failure of bracing (including nighttime bracing) and/or 
corticosteroid injections. The provided examinations did not corroborate significant deficits that are severely 
affecting the enrollee's activities of daily living. There are limited large-scale, long-term references showing the 
safety and efficacy of the requested surgery in this clinical 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 endoscopy, wrist, surgical, with release of transverse carpal ligament, and 
neuroplasty and/or transposition; median nerve at carpal tunnel have not been met. Therefore, we decided that 
the Plan does not have to pre-approve endoscopy, wrist, surgical, with release of transverse carpal ligament 
(29848), and neuroplasty and/or transposition; median nerve at carpal tunnel (64721).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 36200 billed for date of service April 10, 
2023. 
 
You asked the Plan to pay for procedure code 36200. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says payment for code 36200 is bundled into payment for code 36245. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. The rules state that providers may bill services 
with a -59 modifier if the service billed with the modifier indicates a distinct procedural service.  
 
In this case, we have confirmed that code 36200 is a column II code to column I code 36245. While code 
36200 was billed with modifier -59, the medical records provided do not show that the service billed with the -
59 modifier is a distinct procedural service. 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 36200 billed for date of 
service April 10, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve i-Factor allograft. 
 
You asked the Plan to pre-approve i-Factor allograft. You say that you need the procedure to be able to walk 
without pain. The Plan denied your request. The Plan says that i-factor allograft studies have not proven that 
using this product during spinal surgery is better than standard allograft products. 
 
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 i-Factor allograft. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that there is limited published, large-scale, long-term peer-reviewed literature that 
shows this requested allograft to be an effective and/or safe treatment for the noted pathology. Further studies are needed to demonstrate this request has beneficial outcomes compared with conventional treatment. There is 
no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this 
request as an exception. The Plan approved the lumbar laminectomy and fusion. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of i-Factor allograft have not been met. Therefore, we decided that the Plan does 
not have to pre-approve i-Factor allograft.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel testing 
provided on June 27, 2023, and billed with codes 87150, 87481, 87641, 87653, 87798, and 87801. 
 
You asked the Plan to pay for the urine PCR panel testing. You say that this testing should be billed with a 
single panel code. The Plan denied your request. The Plan says this testing was medically necessary.  
 
The Plan must follow Medicare rules. Medicare rules say that a panel cannot be unbundled and billed as 
individual components. 
 
We looked at the file and Medicare rules. This test was not billed with a single panel code as required. Based 
on this information, we decided that Medicare rules for coverage of the urine PCR panel testing have not been met. Therefore, we decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) 
panel testing provided on June 27, 2023, and billed with codes 87150, 87481, 87641, 87653, 87798, and 87801.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel testing 
provided on May 3, 2023, and billed with codes 87150, 87481, 87641, 87653, 87798, and 87801. 
 
You asked the Plan to pay for the urine PCR panel testing. You say that this testing should be billed with a 
single panel code. The Plan denied your request. The Plan says this testing was medically necessary.  
 
The Plan must follow Medicare rules. Medicare rules say that a panel cannot be unbundled and billed as 
individual components. 
 
We looked at the file and Medicare rules. This test was not billed with a single panel code as required. Based 
on this information, we decided that Medicare rules for coverage of the urine PCR panel testing have not been met. Therefore, we decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) 
panel testing provided on May 3, 2023, and billed with codes 87150, 87481, 87641, 87653, 87798, and 87801.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service June 20, 
2023. 
 
You asked the Plan to pay for procedure code 99100. You say that anesthesia related to a colonoscopy should 
be covered with no cost sharing. The Plan denied your request. The Plan says procedure code 99100 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 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service June 20, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric care from October 17, 2023, 
forward. 
 
You asked the Plan to pre-approve inpatient psychiatric care from October 17, 2023, forward. You say that the 
services at issue were medically necessary. The Plan denied your request. The Plan says the services at issue 
were 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 inpatient psychiatric care from October 
17, 2023, forward. Our reviewer says that the enrollee does not meet the criteria for treatment in an acute 
inpatient mental health treatment beyond the date in question of October 17, 2023, forward. Our physician 
reviewer found the enrollee did not require inpatient mental health treatment beyond October 17, 2023, as he 
was not a danger to himself or others and did not have any delusions, auditory or visual hallucinations. It did 
not appear that active treatment was taking place beyond the date in question. It did not appear that the services 
for the dates in question were reasonably expected or medically necessary to improve the enrollees condition 
or for the purpose of diagnosis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient psychiatric care from October 17, 2023, forward have not been met. 
Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric care from October 17, 
2023, forward.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve arthrodesis, posterior or posterolateral technique, single 
interspace; lumbar (22612). 
 
You asked the Plan to pre-approve arthrodesis. You say that this is medically necessary. The Plan denied your 
request. The Plan says the Medicare criteria for reasonable and necessary are not met because use of this device 
as a stand-alone procedure has not been shown to be safe and effective in long term studies. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve arthrodesis. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the Minuteman device is experimental for back pain. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of arthrodesis have not been met. Therefore, we decided that the Plan does not 
have to pre-approve arthrodesis, posterior or posterolateral technique, single interspace; lumbar (22612).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve matrion skin substitute.

You asked the Plan to pre-approve matrion skin substitute. You say that it is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet the requirements for approval.

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 matrion skin substitute. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the provided medical records and review of the current peer-reviewed medical literature do not document that use of the matrion skin substitute has been shown in controlled studies in a Medicare approved journal to result in long term health benefits in patients with a wound from recent Mohs surgery.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of matrion skin substitute have not been met. Therefore, we decided that the Plan does not have to pre-approve matrion skin substitute.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81406 billed for date of service August 2, 
2022.  
 
You asked the Plan to pay for procedure code 81406. You say that these services are supported in the medical 
record. The Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed.  
 
The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 81406 is 2. The MAI value for this code is 3. You billed 4 units of this 
code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were 
actually provided, were correctly coded, and were medically necessary. Based on this information, we decided 
that Medicare rules for coverage of procedure code 81406 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 81406 billed for date of service August 2, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient alcohol detoxification from October 17, 2023, 
forward. 
 
You asked the Plan to pre-approve inpatient alcohol detoxification from October 17, 2023, forward. You say 
that this is medically necessary. The Plan denied your request. The Plan says the requested services are not 
medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient alcohol detoxification from 
October 17, 2023, forward. Our reviewer says that this enrollee does not meet the criteria for treatment in an 
acute inpatient/detoxification treatment beginning October 17, 2023, and could have been treated in a lesser 
restrictive setting. Our physician reviewer found the enrollee did not require inpatient mental health treatment 
beyond the dates in question as he was not a danger to himself or others and did not have any delusions, 
auditory or visual hallucinations. It did not appear that active treatment was taking place beyond the date in 
question. It did not appear that the services for the dates in question were reasonably expected or medically 
necessary to improve the enrollees condition or for the purpose of diagnosis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient alcohol detoxification from October 17, 2023, forward have not been 
met. Therefore, we decided that the Plan does not have to pre-approve inpatient alcohol detoxification from 
October 17, 2023, forward.