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

 
We decided that the Plan does not have to pre-approve bone marrow aspirate and an OssDsign Catalyst 
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 there is limited published, large-scale, 
long-term peer-reviewed literature that shows the requested services to be an effective and/or safe treatment for the enrollee's pathology. Further studies are needed to corroborate that the requested allograft would be as safe 
or better than standard autograft procedures. There is no compelling rationale presented or extenuating 
circumstances noted to support the medical necessity of this request as an exception. There is no specific 
indication provided to support the request for bone marrow aspirate for the approved surgery. There is no 
compelling rationale presented or extenuating circumstances noted to support the medical necessity of bone 
marrow aspiration in conjunction with the planned cervical spine surgery. There is a lack of large-volume, 
long-term peer-reviewed outcome studies to support the use of bone marrow aspirate for this enrollees medical 
condition. Therefore, the requested OssDsign Cattalyst allograft and bone marrow aspirate 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve bone marrow aspirate and an OssDsign Catalyst allograft.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 8 additional speech therapy sessions. 
 
You asked the Plan to pre-approve the therapy services. You say that without skilled intervention the enrollee 
will be unable make further gains. You would like reconsideration based on the records submitted. The Plan 
denied your request. The Plan says additional speech therapy sessions are not medically necessary.  
 
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 the therapy services. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found that the additional requested therapy is not generally accepted as 
specific and effective therapy for the enrollee's condition beyond what was approved by the Plan. The records 
do not demonstrate that the unique skills of a professional therapist are required to provide treatment safely and 
effectively, that the services can be safely and effectively performed only by a therapist, or by or under the 
supervision of a therapist. The requested services are not part of a maintenance program, and the specialized 
skill, knowledge and judgment of a qualified therapist is not required to establish, design and/or deliver a 
program to maintain the enrollee's current condition or to prevent or slow further deterioration. The enrollee 
has had extensive prior therapy for this condition and has had instruction in a home exercise program which 
they can transition to. The enrollee does not require the professional skills of a therapist beyond what was 
already approved.  
 
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 therapy services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 8 additional speech therapy sessions.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computer assisted musculoskeletal surgican 
naviagational ort (055T). 
 
You asked the Plan to pre-approve a computer assisted musculoskeletal surgican naviagational ort. You say 
that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been 
established. Therefore, coverage criteria have not been met. 
 
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 computer assisted musculoskeletal 
surgican naviagational ort. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found computer assisted knee surgery has not 
been shown to be better and safer than conventional open surgery. It is not needed. 
 
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 computer assisted musculoskeletal surgican naviagational ort have not been 
met. Therefore, we decided that the Plan does not have to pre-approve a computer assisted musculoskeletal 
surgican naviagational ort (055T).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the chair component (recliner chair) (A9270). 
 
You asked the Plan to pre-approve the recliner chair. You say that the patient needs a new chair. The Plan 
denied your request. The Plan says the chair (code A9270) incorporating a seat lift mechanism is an item not 
covered by Medicare.  

The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve the chair component (recliner chair) (A9270).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve kyphoplasty (22513, 22515).  
You asked the Plan to pre-approve kyphoplasty. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that percutaneous vertebroplasty and percutaneous 
vertebral augmentation (PVA or Kyphoplasty) procedures will be considered medically reasonable and 
necessary for certain indications. 
 
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 
services are not medically necessary. Our physician reviewer found the enrollee had previous kyphoplasty. 
There is no documentation of fracture bracing or further collapse of the bone. 
 
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 (22513, 22515).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a protective outer surface covering system (L5962). 
 
You asked the Plan to pre-approve a protective outer surface covering system (L5962). You say that the 
requested protective outer surface covering system (L5962) is medically necessary.  The Plan denied your 
request. The Plan says the requested protective outer surface covering system (L5962) 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 a protective outer surface covering 
system (L5962). Our reviewer says that the requested protective outer surface covering system (L5962) is not 
medically necessary.  Our physician reviewer found the enrollee is a K3 level ambulator and requires a transtibial prosthesis for mobility and performing daily activities. He requires a new prosthetic socket due to 
volume change of his residual limb and replacement prosthetic foot given that his current one in delaminating. 
However, there is insufficient documentation indicating that the enrollee requires a protective outer surface 
covering or is exposed to unusually harsh environmental situations. 
 
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 protective outer surface covering system (L5962) have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a protective outer surface covering system 
(L5962).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81345 billed for date of service April 5, 
2023. 
 
You asked the Plan to pay for the billed services. You say that the treatment sought was medically necessary. 
The Plan denied your request. The Plan says one code must be submitted for the panel. 
 
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 file shows that a primary immunodeficiency gene panel was billed with multiple codes, including code 
81345. The panel testing was not billed with a single code as required. Based on this information, we decided 
that Medicare rules for coverage of the billed services have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 81345 billed for date of service April 5, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.

You asked the Plan to pre-approve the LTACH services. You say that you are appealing the denial. The Plan
denied your request. The Plan says the request is not medically necessary.

The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.

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 LTACH services. Our reviewer says
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our
physician reviewer found that you do not require services at the LTACH that are not available at the acute care
hospital where you currently receiving care. All medically necessary care is being provided in the current acute
care 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 the LTACH services have not been met. Therefore, we decided that the Plan
does not have to pre-approve LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes A4221 and A4223 billed for date of service 
February 21, 2023 to February 25, 2023. 
 
You asked the Plan to pay for procedure codes A4221 and A4223. You say that you disagree with the denial. 
The Plan denied your request. The Plan says the billed codes are invalid for Medicare purposes.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure codes A4221 and A4223 have a Status Indicator of X on the Physician Fee Schedule. 
This means that procedure codes A4221 and A4223 are excluded from Medicare coverage. Based on this 
information, we decided that Medicare rules for coverage of procedure codes A4221 and A4223 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure codes A4221 and A4223 billed for 
date of service February 21, 2023 to February 25, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for segmental pneumatic appliances (E0669) billed for date of 
service April 6, 2023. 
 
You asked the Plan to pay for segmental pneumatic appliances. You say that you have billed the services at 
issue correctly. The Plan denied your request. The Plan says rules for payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that claims must specify whether equipment is rented 
or purchased.  

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of segmental pneumatic appliances have not been met. Specifically, the items at issue have not been 
billed with required modifiers to specify whether they are rented or purchased. Therefore, we decided that the 
Plan does not have to pay for segmental pneumatic appliances (E0669) billed for date of service April 6, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87798 billed for September 27, 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 procedure code 87798 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 87798 is infectious agent detection by nucleic acid (DNA 
or RNA), not otherwise specified; amplified probe technique, each organism. 
 
We find that CPT code 87798 is not supported in the medical record. Specifically, this is a not otherwise 
specified code and a complete description was not included in the documentation. 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 pay for procedure code 87798 billed for September 27, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bone marrow aspirate (20939). 
 
You asked the Plan to pre-approve a bone marrow aspirate. You say that this is medically necessary. The Plan 
denied your request. The Plan says the clinical value and effectiveness of bone marrow aspirate in the setting of 
spinal 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 bone marrow aspirate. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found bone marrow aspirate is experimental when used as bone graft material in spine 
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 a bone marrow aspirate have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a bone marrow aspirate (20939).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes S1015, S8301, A4556, A4557, and A4649 
billed for date of service May 2, 2023. 
 
You asked the Plan to pay for the billed services. You say that there is no reason to pay less than expected. The 
Plan denied your request. The Plan says the billed codes are not 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 codes S1015 and S8301 have a Status Indicator of I on the Physician Fee Schedule. 
This means that procedure codes S1015 and S8301 are not valid for Medicare purposes. We find that procedure 
codes A4556, A4557, and A4649 have a Status Indicator of P. This means that no separate payment is allowed. 
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 S1015, S8301, A4556, 
A4557, and A4649 billed for date of service May 2, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 power wheelchair with single power option 
and accessories (E0955, E0995, E1002, E1028, E2209, E2310, E2361, E2607, E2615, K0040, K0108, K0856). 
 
You asked the Plan to pre-approve a group 3 power wheelchair with single power option and accessories. You 
say that the services are necessary. The Plan denied your request. The Plan says based on the documentation 
provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that power mobility devices are covered when specific 
criteria are met.  
 
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 group 3 power wheelchair with single 
power option and accessories. Our reviewer says that the services are not medically necessary. Our physician 
reviewer found the enrollee does not have high risk for skin breakdown, use a catheter intermittently, have 
spasticity or require an alternative means of managing power drive. 
 
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 group 3 power wheelchair with single power option and accessories have not 
been met. Therefore, we decided that the Plan does not have to pre-approve a group 3 power wheelchair with 
single power option and accessories (E0955, E0995, E1002, E1028, E2209, E2310, E2361, E2607, E2615, 
K0040, K0108, K0856).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 4 additional home health occupational therapy visits. 
 
You asked the Plan to pre-approve the additional home health services. You say that these services are 
medically necessary because of encounter of other orthopedic after care and muscle weakness. 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 the additional home health services. 
Our reviewer says that the services are not medically reasonable and necessary. Our physician reviewer found 
the records do not show that 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 to 
maintain the enrollee's level of function and/or prevent deterioration beyond what was approved by the health 
plan. The enrollee and caregiver can use the approved therapy sessions to have thorough training in a home 
exercise program. The documentation does not support the enrollee requires the ongoing skills of a therapist for 
four remaining sessions. 
 
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 additional home health services have not been met. Therefore, we decided 
that the Plan does not have to pre-approve 4 additional home health occupational therapy visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable controller with harness upgrade and 
electronic connection. 
 
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 diabetes, diabetic neuropathy, and back pain. He is independent with feeding, dressing, grooming, and toileting. The records 
show that he has sufficient strength and function in his upper extremities to manage the standard power drives. 
The requested expandable controller with harness upgrade and electronic connection are therefore not 
reasonable or medically 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 expandable controller with harness upgrade and electronic connection.