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

 
We decided that the Plan does not have to pre-approve the bone marrow aspirate. 
 
You asked the Plan to pre-approve the bone marrow aspirate. You say that the enrollee is in a lot of pain. You 
also say that this would better their quality of life. 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 the bone marrow aspirate. Our reviewer 
says that the request for bone marrow aspirate is not considered medically reasonable and necessary in this 
case. Our physician reviewer found bone marrow aspirate remains experimental in spine surgery when used as 
bone graft material. Therefore, the reviewer found that bone marrow aspirate is not medically reasonable or 
necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the bone marrow aspirate have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the bone marrow aspirate.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a preventive-medicine evaluation and management 
service (99397). 
 
You asked the Plan to pre-approve a preventive-medicine evaluation and management service. You say that the 
requested service is a medical necessity for you. The Plan denied your request. The Plan says the requested 
service is not covered by Medicare.  
 
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 99397 has a Status Indicator of N on the Physician Fee Schedule. This means that 
procedure code 99397 is not covered by Medicare. Based on this information, we decided that Medicare rules for coverage of a preventive-medicine evaluation and management service have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a preventive-medicine evaluation and management service 
(99397).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an additional unit of procedure code 813007 billed for date 
of service September 27, 2022.  
 
You asked the Plan to pay for procedure code 81307. You say that the treatment sought was medically 
necessary. 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 claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 81307 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage have not 
been met. Therefore, we decided that the Plan does not have to pay for an additional unit of procedure code 
813007 billed for date of service September 27, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the custom fabricated abutment (D6057) and the 
abutment supported to crown (D6058) for tooth #27 provided by an out-of-network provider on January 4, 
2023. 
 
You asked the Plan to pay more for the dental services. You say that the dentist should be in-network and you 
should only pay 50% for the dental services. The Plan denied your request. The Plan says you are responsible 
for any charged amount above the Plan's cost-sharing amount when your services are received from an out-of-
network provider. Also, the proper cost share was applied. 
 
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. 
 
For the custom fabricated abutment (D6057) the total amount billed was $880 and the total allowed amount 
was $94.88 leaving a difference of $785.12 ($880 billed - $94.88 allowed). The total amount billed for the 
abutment supported to crown (D6058) was $1,400 and the total allowed amount was $254.13 leaving a 
difference of $1,145.87 ($1,400 billed - $254.13 allowed). The total difference amount for both dental services 
was $1,930.99 ($785.12 difference + $1,145.87 difference). The Explanation of Benefits does not show that a 
50% coinsurance was charged and only the difference between the out-of-network provider's charges and the 
Plan's allowed amount was charged. 
 
You have been asked to pay the difference between the out-of-network provider's charges and the Plan's 
payment. 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 pay more for the custom fabricated abutment (D6057) and 
the abutment supported to crown (D6058) for tooth #27 provided by an out-of-network provider on January 4, 
2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87640 billed for date of service December 
22, 2022. 
 
You asked the Plan to pay for procedure code 87640. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says payment for code 87640 is bundled into payment for code 87641. 
 
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 87640 
is a column II code to column I code 87641. 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 87640 billed for date of service December 22, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a red color anodize package, aluminum rigid side 
guards, and pneumatic propulsion tires. 
 
You asked the Plan to pre-approve these services. You say that the enrollee has a complex medical history and 
cerebral palsy. The Plan denied your request. The Plan says accessories are for use outside of the home. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The requested aluminum rigid side guards and pneumatic propulsion tires are used for features that are used 
outside of the home. Although these items may be helpful, neither Medicare nor the Plan covers equipment for 
use outside the home. The requested red color anodize package does not serve a purpose that is medical in 
nature. Therefore, we decided that the Plan does not have to pre-approve a red color anodize package, 
aluminum rigid side guards, and pneumatic propulsion tires.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a facet joint injection. 
 
You asked the Plan to pre-approve a facet joint injection. You say that a facet joint injection is medically 
necessary. The Plan denied your request. The Plan says the requested facet joint injection does not meet the 
Medicare LCD coverage criteria.  
 
The Plan follows Medicare rules. Medicare rules say that facet joint injections are covered when the criteria 
listed in the Medicare rules section of this decision 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 facet joint injection. Our reviewer 
says that the requested facet joint injection is not considered medically necessary in this case. Our physician 
reviewer found the enrollee has a history of chronic low back pain due to lumbar spondylosis without 
myelopathy. The enrollee has been treated with medication and underwent bilateral lumbar medial branch 
blocks (MBBs) on February 21, 2023, which provided 50% improvement. The enrollees provider has 
recommended repeat bilateral lumbar MBBs with progression to a radiofrequency ablation. In this case, the 
initial MBBs performed on February 21, 2023 provided only 50% pain relief. The review has determined that 
the requested MBBs/facet joint procedure do not meet the Medicare LCD coverage criteria. 
 
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 facet joint injection have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a facet joint injection.
Appeal type: ER
Decision: Favorable

 
We decided that the Plan has to pay for the COVID-19 test (87426) provided on May 28, 2022. 
 
You asked the Plan to pay for the COVID-19 test (87426). You say that all services rendered were medically 
necessary and the provider should not be penalized for providing emergency services. You say that payment 
was below the customary rate and additional reimbursement at the highest rate is requested. The Plan denied 
your request. The Plan says that the adjustment in provider payment reflects recent changes made in 
CMS/Medicare reimbursement levels due to sequestration.  
 
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. Specifically, the Plan denied the laboratory service as a packed service. 
However, the Outpatient Prospective Payment System (OPPS) status indicator of the code does not indicate 
that payment for procedure code 87426 would be packaged with payment for the emergency department code. 
Therefore, we decided that the Plan has to pay for the COVID-19 test (87426) provided on May 28, 2022, at 
the Medicare approved payment rate  
 
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 81226, 81240, 81241, and 81328 for date of 
service January 23, 2023. 
 
You asked the Plan to pay for procedure codes 81226, 81240, 81241, and 81328. You say that you disagree 
with the Plan's denial. The Plan denied your request. The Plan says the services are not payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT codes 81226, 81240, 81241, and 81328 are not supported in the medical record. Specifically, 
the documentation submitted did not include documentation of Unlisted molecular pathology procedure. The 
medical records indicate that Hematology Profile Plus was performed. This means codes 81226, 81240, 81241, 
and 81328 are not supported and there is a more appropriate code to be billed for the services rendered. Based 
on this information, we decided that Medicare rules for coverage of procedure codes 81226, 81240, 81241, and 
81328 have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 81226, 
81240, 81241, and 81328 for date of service January 23, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a harness (E2313), an expandable controller (E2377), 
and an electronic connection device (E2311).  
 
You asked the Plan to pre-approve the upgraded electronics. You say that you are requesting reconsideration of 
the denied authorization. The Plan denied your request. The Plan says the requested items 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 upgraded electronics. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee does have use of the upper extremities and can operate and control 
the power options using the switches that are included in the basic wheelchair. 
 
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 upgraded electronics have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a harness (E2313), an expandable controller (E2377), and an electronic 
connection device (E2311).
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 March 6, 
2023. 
 
You asked the Plan to pay for procedure code 99100. You say that you disagree with the Plan's denial. 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 March 6, 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 admission to an IRF is medically necessary. The Plan denied your request. The Plan says admission to an IRF does not meet criteria.

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 enrollee was admitted for respiratory failure and congestive heart failure. 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 this 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation system (E2300). 
 
You asked the Plan to pre-approve a power seat elevation system. You say that the enrollee needs a power lift 
for their wheelchair in order to reach higher places. the enrollee's home is not handicap accessible and needs 
this component for their independence. The Plan denied your request. The Plan says a power seat elevation 
feature (E2300) is considered primarily non-medical in nature and non-covered. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.   

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a power seat elevation system have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a power seat elevation system (E2300).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87633 and 87634 for date of service January 
3, 2023. 
 
You asked the Plan to pay for procedure codes 87633 and 87634. You say that you disagree with the Plan's 
denial. 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 procedure code 87633 
have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 87633 and 
87634 for date of service January 3, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Signatera genetic test (0340U). 
 
You asked the Plan to pre-approve a Signatera genetic test. 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 this Medicare contractor will provide limited 
coverage for minimally invasive molecular deoxyribonucleic acid (DNA) and ribonucleic acid (RNA) tests that 
detect minimal residual disease (MRD) in patients with a personal history of cancer. 
 
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 Signatera genetic test. Our reviewer 
says that the services are not medically necessary. Our physician reviewer found there was no indication 
positron emission tomography (PET) and other imaging alone would not be sufficient or appropriate for 
monitoring therapy. You were not noted to be currently using an immune-checkpoint inhibitor or with plans for 
starting one. Also, current NCCN guidelines do not recommend use of MRD testing such as Signatera. 
Therefore, the enrollee does not meet LCD coverage. 
 
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 Signatera genetic test have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Signatera genetic test (0340U).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Hyalgan injections. 
 
You asked the Plan to pre-approve Hyalgan injections. You say that this is medically necessary. The Plan 
denied your request. The Plan says the medical records we received from your provider, and dated 07/05/2023, does not indicate that you have failed at least three months of conservative  therapy. We have determined that the use of this drug for your illness is not reasonable and necessary by Medicare guidelines and is not covered based on the information we have received. Therefore, the request for an authorization for Hyalgan Injections of the left knees has been denied. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
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 Hyalgan injections. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the medical records, dated 
07/05/2023, do not indicate that the enrollee has failed at least three months of conservative therapy. According 
to Medicare guidelines, the use of the requested drug 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 Hyalgan injections have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Hyalgan injections.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pre-approve a Signatera test (0340U). 
 
You asked the Plan to pre-approve a Signatera test. You say that the services are necessary. The Plan denied 
your request. The Plan says that medical necessity has not been established. Therefore, coverage criteria have 
not been met. 
 
The Plan follows Medicare rules. Medicare rules say that this Medicare contractor will provide limited 
coverage for minimally invasive molecular deoxyribonucleic acid (DNA) and ribonucleic acid (RNA) tests that detect minimal residual disease (MRD) in patients with a personal history of cancer. 
 
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 Signatera test. Our reviewer says that 
the services are medically necessary. Our physician reviewer found the Signatera test as ordered meets all of 
the criteria for breast cancer. Given the T1cNx stage along with high Oncotype Dx score as well as PR- status, 
SIgnatera is medically reasonable and necessary for the enrollee. 
 
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 Signatera test have been met. Therefore, we decided that the Plan has to pre-
approve a Signatera test (0340U).  
 
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.