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

 
We decided that the Plan does not have to pre-approve an InFUSE BMP allograft. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has persistent low back 
pain with lower extremity radicular symptoms. The requested spinal fusion is approved. 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 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. Therefore, the  
InFUSE BMP allograft 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an InFUSE BMP allograft.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81345 billed for date of service July 27, 
2022. 
 
You asked the Plan to pay for procedure code 81345. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says payment for code 81345 is bundled into 
payment for code 0089U. 
 
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 81345 
is a column II code to column I code 0089U. 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 81345 billed for date of service July 27, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81265 billed for date of service June 24, 
2022. 
 
You asked the Plan to pay for procedure code 81265. You say that this service was necessary and is supported 
in the medical record. The Plan denied your request. The Plan says this service is not supported in the medical 
record and there is no evidence that this test was requested. 
 
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 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 procedure code 81265. Our reviewer says that this code is 
not supported in the records provided. Our reviewer found the medical documentation does not support the use 
of procedure 81265 as the lab results do not show that the lab tested to evaluate short tandem repeat markers to 
compare genetic similarity in the patient and specimen from another person. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 81265 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 81265 billed for date of service June 24, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99153 billed for November 30, 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 the services are not separately payable. 
 
The Plan must follow Medicare rules. The rules say that a professional component (PC)/technical component 
(TC) indicator of 3 identifies technical component only stand alone codes. 
 
We looked at the file and Medicare rules. Procedure code 99153 has a PC/TC indicator of 3 and no separate PC payment. Therefore, we decided that the Plan does not have to pay for procedure code 99153 billed for 
November 30, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code A4215 billed for date of service November 
28, 2022. 
 
You asked the Plan to pay for procedure code A4215. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the billed code is statutorily excluded. 
 
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 A4215 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code A4215 is statutorily excluded. Based on this information, we decided that Medicare rules for 
coverage of procedure code A4215 have not been met. Therefore, we decided that the Plan does not have to 
pay for procedure code A4215 billed for date of service November 28, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 16 additional home health care visits.  
You asked the Plan to pre-approve home health care. You say that you are appealing this denial. The Plan 
denied your request. The Plan says the services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health care. Our reviewer says 
that the services are not medically reasonable and necessary. Our physician reviewer found the enrollee has a 
chronic condition and is functioning at a level of care which may improve with a home exercise program. The 
record does not include a rationale for continued skilled therapy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health care have not been met. Therefore, we decided that the Plan does 
not have to pre-approve 16 additional home health care visits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gingivectomy or gingivoplasty to allow access for 
restorative procedure, per tooth (D4212), and core buildup, including any pins when required (D2950) provided 
on December 29, 2022. 
 
You asked the Plan to pay for the dental codes represented by D2790, D4212, and D2950. You say that you are 
requesting reconsideration stating that the claim shouldn't have been submitted until the permanent crown was 
cemented in 2023. The Plan denied your request.  

The Plan says there is no coverage for D2950 core buildup, including any pins when required and D4212 
gingivectomy or gingivolplasty to allow access for restorative procedure, per tooth. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
gingivectomy or gingivoplasty to allow access for restorative procedure, per tooth (D4212), and core buildup, 
including any pins when required (D2950) provided on December 29, 2022.
Appeal type: Home Health
Decision: Favorable

 
We decided that the Plan has to pre-approve 9 additional home health physical therapy visits. 
 
You asked the Plan to pre-approve home health care. You say that the enrollee has been having a hard time 
sitting up without leaning to one side. The Plan denied your request. The Plan says that this is not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health care. Our reviewer says 
that the services are medically reasonable and necessary. Our physician reviewer found the enrollee has a 
progressive neurological condition and has made progress in the first 6 home health sessions. Clinical 
documentation shows plans to work on stand pivot transfers with the enrollee and instruction on home exercise 
program only due to the sixth session being the last approved session. Although there have been no recent 
hospitalizations, the enrollee has documented neurologic deficits. A skilled therapist would be expected to be 
required to teach the enrollee/family new transfer technique and many of the other appropriate goals set have 
not yet been met. Skilled therapy services are required to effectively provide treatment, care, and/or services in 
order to improve the enrollee's level of function, or to establish/perform a maintenance 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 home health care have been met. Therefore, we decided that the Plan has to pre-
approve 9 additional home health 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 84480, 84436 and 84479 billed for date of 
service May 4, 2022.  

You asked the Plan to pay for procedure codes 84480, 84436 and 84479. You say that these services are 
supported in the medical records. The Plan denied your request. The Plan says payment for codes 84480, 84436 
and 84479 is bundled into payment for codes 84481 and 84439. 
 
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 codes 
84480, 84436 and 84479 are column II codes to column I codes 84481 and 84439 with a modifier indicator of 
0. The column II codes are 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 codes 84480, 84436 and 
84479 billed for date of service May 4, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pathogen detection by nucleic acid provided on 
December 16, 2022, billed with one unit of code 87631 and 12 units of 87798.  
 
You asked the Plan to pay for the genetic pathogen detection testing as billed. You say that this was medically 
necessary and should be paid. The Plan denied your request. The Plan says the claim for this molecular 
pathology testing did not include the required unique identifier. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of the genetic pathogen 
detection testing as billed have not been met. Therefore, we decided that the Plan does not have to pay for the 
pathogen detection by nucleic acid provided on December 16, 2022, billed with one unit of code 87631 and 12 
units of 87798.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab tests (8799 and 87900) provided on October 5, 2022. 
 
You asked the Plan to pay for lab tests. You say that these services were medically necessary. The Plan denied 
your request. The Plan says these codes are not supported in the medical record. 
 
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 87899 is infectious agent antigen detection by 
immunoassay with direct optical observation; not otherwise specified. The CPT Code Manual definition of 
code 87900 is infectious agent drug susceptibility phenotype prediction using regularly updated genotypic bioinformatics. 
 
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 the enrollee went into the clinic for urinary tract infection (UTI) 
urinalysis and that code is encompassed with these procedures. 
 
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 lab tests (8799 and 87900) provided on October 5, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an attendant control (E2331). 
 
You asked the Plan to pre-approve an attendant control. You say that the requested item is medically necessary. 
The Plan denied your request. The Plan says that this item is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that if an attendant control is provided in addition to a 
beneficiary-operated drive control system, it will be denied as non-covered. 
 
We looked at the file and Medicare rules. An attendant control is not covered when provided in addition to a 
beneficiary-operated drive control system. Therefore, we decided that the Plan does not have to pre-approve an 
attendant control (E2331).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care after May 23, 2023. 
 
You asked the Plan to pre-approve SNF care. You say that the enrollee would like to continue receiving skilled 
care at the facility. The Plan denied your request. The Plan says services have been approved for May 12, 2023, 
to May 23, 2023. Services after this date remain denied as not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines.  Our 
physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing 
facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care after May 23, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on December 17, 2022, billed 
with codes 81218, 81209, 81314, 81345 and 81272. 
 
You asked the Plan to pay for the genetic testing billed. You say that this test was medically necessary and is 
supported in the medical record. 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 
December 17, 2022, billed with codes 81218, 81209, 81314, 81345 and 81272.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve upgraded electronics (E2311, E2313, E2377) and seat 
elevation feature (E2300). 
 
You asked the Plan to pre-approve upgraded electronics and seat elevation feature. You say that when three or 
more power seating functions/actuators/motors are provided, upgraded electronics are allowed. The Plan denied your request. The Plan says a seat elevator does not serve a primary medical purpose and is statutorily 
non-covered. The Plan also says that the upgraded electronics 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 upgraded electronics and seat elevation 
feature. Our reviewer says that the requested upgraded electronics are not considered medically reasonable and 
necessary in this case.  Our physician reviewer found the provided documentation indicates the enrollee has use 
of their upper extremity and can operate and control the power options using the switches that are included in 
the basic wheelchair. Therefore, the reviewer found that the upgraded electronics are 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 upgraded electronics and seat elevation feature have not been met. Therefore, 
we decided that the Plan does not have to pre-approve upgraded electronics (E2311, E2313, E2377) and seat 
elevation feature (E2300).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve re- evaluation limited problem focused (D0170). 
 
You asked the Plan to pre-approve re- evaluation. You say that this should be covered. The Plan denied your 
request. The Plan says this is not a covered service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve re- 
evaluation limited problem focused (D0170).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve kyphoplasty services (22513, 22515). 
 
You asked the Plan to pre-approve kyphoplasty. 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 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 kyphoplasty. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case.  Our physician reviewer 
found that there is no documentation of bracing. More conservative measures are needed to demonstrate the 
medical necessity of 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 kyphoplasty have not been met. Therefore, we decided that the Plan does not 
have to pre-approve kyphoplasty services (22513, 22515).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the vascular ultrasound provided on March 
9, 2023. 
 
You asked the Plan to waive the copayment for the vascular ultrasound. You say that you were charged two 
copayments. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $25 
copayment for vascular ultrasounds.  
 
You have been asked to pay a $25 copayment for the vascular ultrasound. This item/service falls within the 
outpatient diagnostic tests and therapeutic services benefit category. This means that you have been asked to 
pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you 
agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the 
copayment for the vascular ultrasound provided on March 9, 2023.