Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a replacement iLevel seat elevator (K0108). 
 
You asked the Plan to pre-approve a replacement seat elevator. You say that the lift on your current wheelchair 
is not working. You also say that without the lift function there is a high risk of falling. The Plan denied your 
request. The Plan says that the code used for the seat elevator does not match the item requested. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. We find that the Plan has not supported that the item, for which repair is being 
requested, should be coded differently. The Plan has not substantiated their denial reason. In addition, coding 
arguments should not generally be used to deny pre-service requests. The appellant will not be the one billing 
the services, and the Plan should work with their network providers to ensure that the repairs or items provided 
are correctly coded on the claim when submitted.   Therefore, we decided that the Plan has to pre-approve a 
replacement iLevel seat elevator (K0108).  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory testing provided on October 5, 2022. 
 
You asked the Plan to pay for lab tests. You say that you do not have access to physician notes or reports. The 
Plan denied your request. The Plan says these 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 CPT code. 
 
In this case, the CPT Code Manual definition of code 87045 is culture, bacterial; stool, aerobic, with isolation 
and preliminary examination (eg, KIA, LIA), Salmonella and Shigella species. The CPT Code Manual 
definition of code 87046 is culture, bacterial; stool, aerobic, additional pathogens, isolation and presumptive 
identification of isolates, each plate. The CPT Code Manual definition of code 87427 is infectious agent 
antigen detection by immunoassay technique (eg, enzyme immunoassay [EIA], enzyme-linked immunosorbent 
assay [ELISA], fluorescence immunoassay [FIA], immunochemiluminometric assay [IMCA]), qualitative or 
semiquantitative; Shiga-like toxin.  

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 lab tests. Our reviewer says that these codes do not meet 
criteria for payment. Our reviewer found there is no documentation supporting that the codes in question were 
performed. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of lab tests have not been met. Therefore, we decided that the Plan does not have 
to pay for laboratory testing provided on October 5, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for an expandable controller (E2377), an access
harness for an expandable controller (E2313), and an electronic connection (E2311) for the enrollee.

You asked the Plan to provide coverage for the requested upgraded electronics. The Plan denied your 
request. The Plan says the Medicare coverage criteria were not met. Maximus overturned the Plans 
denial. The Plan requested a reopen and stated that Maximus did not apply the correct criteria. The 
Plan noted the medical records show the enrollee has sufficient upper extremity strength to operate 
the standard switches that come with the approved power wheelchair.

The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that items and
services that are not medically necessary are not covered. The available clinical documentation in the case file
does not support that the requested upgraded electronics were medically reasonable and necessary for the
enrollee in this case. The notes do not show the medical necessity of controlling the power options through a
joystick. Therefore, we decided that the Plan does not have to provide coverage for an expandable controller
(E2377), an access harness for an expandable controller (E2313), and an electronic connection (E2311) for the
enrollee.
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 this is medically necessary. The Plan 
denied your request. The Plan says the clinical value and effectiveness of i-FACTOR allograft in the setting of 
a lumbar fusion procedure 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 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 there is limited published, large-scale, long-term peer-reviewed literature that shows 
the i-FACTOR 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 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 laboratory service (87086) provided April 6, 2023. 
 
You asked the Plan to pay for the laboratory service. You say that the claim should be paid. The Plan denied 
your request. The Plan says the service is not supported by the records. 
 
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 87086 is culture, bacterial; quantitative colony count, 
urine. 
 
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 laboratory service. Our reviewer found lab code 87086 
could not be verified as the documentation does not support a culture was taken, nor was there a result of the 
culture.  
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 laboratory service have not been met. Therefore, we decided that the Plan 
does not have to pay for the laboratory service (87086) provided April 6, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the initial hospital inpatient care (99223) provided on 
January 19, 2023. 
 
You asked the Plan to pay for the inpatient care. You say that the service was billed correctly and should be 
paid. The Plan denied your request. The Plan says the medical records submitted do not include initial hospital 
inpatient or observation care, per day for the evaluation and management of a patient that requires a medically 
appropriate history and/or examination and a high level of medical decision-making or must meet or exceed 75 
minutes of total time. Therefore, code 99223 is not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, 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 physician 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 care. Our reviewer found the medical 
records submitted did not include initial hospital inpatient or observation care, per day for the evaluation and 
management of a patient that requires a medically appropriate history and/or examination and a high level of 
medical decision-making or must meet or exceed 75 minutes of total time (non-face to face to face total time) 
spent on the date of the encounter for the billed date of service. The review has determined that CPT code 
99223 was not supported. There was a comprehensive history and exam but no medical decision making of 
high 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 the inpatient care have not been met. Therefore, we decided that the Plan does 
not have to pay for the initial hospital inpatient care (99223) provided on January 19, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve stereotactic body radiation therapy (SBRT). 
 
You asked the Plan to pre-approve SBRT. You say that the requested services are a medical necessity for the 
enrollee. The Plan denied your request. The Plan says the requested services are not 
experimental/investigational for the enrollee's condition. 
 
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 SBRT. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the coverage criteria are not met as bone metastases is not a covered indication. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SBRT have not been met. Therefore, we decided that the Plan does not have to 
pre-approve stereotactic body radiation therapy (SBRT).
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 it is believed that with acute inpatient therapy the 
enrollee will regain their independence. The Plan denied your request. The Plan says an IRF admission is not 
medically necessary, but skilled therapies as an outpatient or at a skilled nursing facility (SNF) may be 
approved upon request.  
 
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 the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's 
medical problems are stable and there are no complex nursing or rehabilitation needs. The enrollee does not 
require treatment by multiple therapies, including either physical therapy or occupational therapy, and an 
intensive rehabilitation therapy program. While the medical record supports a need for physical and/or 
occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary 
care can be provided in a different level of care. There is not a reasonable expectation that the enrollee will be 
able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the skin substitute, InnovaMatrix AC (A2001). 
 
You asked the Plan to pre-approve the skin substitute. You say that the services are medically necessary. The 
Plan denied your request. The Plan says the 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 the 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 Health Plans denial should be upheld. The documentation is insufficient to show 
treatment failure to standard therapy. As such, the requested skin graft substitute is not medically necessary or 
reasonable. 
 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 skin substitute have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the skin substitute, InnovaMatrix AC (A2001).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 30117 provided May 12, 2023. 
 
You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. 
The Plan says that the medical records indicate that repair of nasal valve collapse was performed. The Plan 
states there's a more appropriate CPT code that should be used to bill for the service provided (30469); 
therefore, the validity and accuracy of the service cannot be verified. 
 
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 30117 is excision or destruction (eg, laser), intranasal lesion; internal approach. 
 
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 service. Our reviewer found the documentation supports 
the use of procedure code 30117, the vivaer device is used for the laser destruction of intranasal lesions. 
Procedure code 30469 does not describe the procedure nor does it support the procedure being performed. 
 
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 service have been met. Therefore, we decided that the Plan has to pay for 
procedure code 30117 provided May 12, 2023.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on August 25, 2023, to 
September 8, 2023. 
 You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says the services are not separately reportable. 
 
The Plan must follow Medicare rules. Medicare rules say that diagnostic services provided to a beneficiary by 
the admitting hospital, or by an entity wholly owned or wholly operated by the admitting hospital within 3 days 
prior to and including the date of the beneficiary's admission are deemed to be inpatient services and included 
in the inpatient payment. 
 
We looked at the file and Medicare rules. The records show that the claim in dispute was billed for dates of 
service starting on August 25, 2023, which is within the 3 days prior to inpatient admission. Based on this 
information, we decided that Medicare rules for coverage of the practitioner services provided have not been 
met. Therefore, we decided that the Plan does not have to pay for practitioner services provided on August 25, 
2023, to September 8, 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 the enrollee requires oversight from a physician on a 
daily basis. You also say that In order for the enrollee to return to prior level of function, they will need 3 hours 
of physical therapy and occupational therapy daily. The Plan denied your request. The Plan says based on the 
available information, admission to IRF is not reasonable and necessary, as the enrollee's condition does not 
meet the Medicare rules.  
 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 the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for surgical repair of a femur fracture after a fall. Medical problems are stable. There are no 
complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, 
including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. 
While the medical record supports a need for physical and/or occupational therapy, there is no documented 
need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. 
There is not a reasonable expectation that the enrollee will be able to fully participate in and benefit from the 
intensive rehabilitation therapy program provided in an IRF.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive pharmacogenetics panel (81226) 
provided August 1, 2023.  
 
You asked the Plan to pay for the laboratory testing. You say that you do not personally see the patients, you 
are dependent on receiving patient information from the ordering provider. The Plan denied your request. The 
Plan says the clinical value and effectiveness of comprehensive pharmacogenetic testing 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 pay for the laboratory testing. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there was no documented plan to change medications or other treatments for the enrollee's 
conditions to support this genetic testing, nor has this specific testing been shown to lead to improved outcomes 
long-term to support their use for screening. Therefore, this request for PGx testing will be considered not 
medically necessary and the criteria has not been met.  
 
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 laboratory testing have not been met. Therefore, we decided that the Plan 
does not have to pay for the comprehensive pharmacogenetics panel (81226) provided August 1, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on August 24, 2023. 
 
You asked the Plan to pay for laboratory services. You say that this service is supported in the records proving 
medical necessity. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for laboratory services 
provided on August 24, 2023.