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

 
We decided that the Plan does not have to pre-approve Stryker BIO4 allograft. 
 
You asked the Plan to pre-approve Stryker BIO4. You say that the enrollee needs this surgery immediately to 
refrain from severe pain. The Plan denied your request. The Plan says the clinical value and effectiveness of 
Stryker BIO4 allograft in the setting of lumbar decompression and fusion have not been demonstrated. 
 
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 Stryker BIO4. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found Stryker BIO4 allograft is experimental. More research is 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 Stryker BIO4 have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Stryker BIO4 allograft.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (87481, 87491, 87563, 87591, 87640, 87653, 
87661) provided on April 20, 2023. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the claim cannot be paid 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 87481, 87491, 87563, 87591, 87640, 87653, & 87661 are not supported in the medical 
record. Specifically, multiple unbundled codes were billed for a single panel. Based on this information, we 
decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the 
Plan does not have to pay for lab services (87481, 87491, 87563, 87591, 87640, 87653, 87661) provided on 
April 20, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sacroiliac joint arthrodesis. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the documentation does not show at least 75% pain relief from previous injections to 
this joint for at least the expected duration of the anesthetic used. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that detailed documentation is not evident regarding imaging or radiographic evidence supporting left 
sacroiliac pathology. There are no imaging studies of the lumbar and/or pelvis/sacroiliac post-operative from 
the recent lumbar surgery on 4/20/23. Updated imaging is typically indicated as the recent surgery included T11-S1 posterior spinal instrumentation and fusion. The documentation does not rule out other plausible causes 
of pain (potentially including the fusion construct.) There are limited large-scale, long-term references showing 
the safety and efficacy of the requested surgery in this clinical setting. There is no compelling rationale 
presented or extenuating circumstances noted to support the medical necessity of this request as an exception. 
Therefore, the requested sacroiliac joint arthrodesis 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve sacroiliac joint arthrodesis.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (80053, 83540 and 85025) provided on 
May 3, 2023. 
 
You asked the Plan to pay for laboratory services. You say that these services were necessary and are supported 
in the medical record. The Plan denied your request. The Plan says there is inconsistent information regarding 
these services. 
 
The Plan must follow Medicare rules. Medicare rules say that any independent laboratory performing tests 
covered by CLIA must submit the CLIA number on the claim. Laboratory claims submitted without the 
required CLIA number are returned as unprocessable. If the CLIA number is submitted on the claim, but is 
inconsistent with the CLIA format, the A/B MAC (B) returns the claim as unprocessable. 
 
We looked at the file and Medicare rules. This claim was submitted with a CLIA number which is inconsistent 
with the CLIA number reported in the medical records. This discrepancy means we cannot verify who actually 
provided these services. Based on this information, we decided that Medicare rules for coverage of laboratory 
services have not been met. Therefore, we decided that the Plan does not have to pay for laboratory services 
(80053, 83540 and 85025) provided on May 3, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on May 17, 2023. 
 
You asked the Plan to pay for the laboratory services. You say that this testing was medically necessary. 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 the laboratory services 
provided on May 17, 2023.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gelsyn-3 (J7328). 
 You asked the Plan to pre-approve Gelsyn-3. The Plan denied your request. The Plan says this request does not 
meet the Plan's Part B step therapy criteria for the requested viscosupplement device. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Gelsyn-3. Our reviewer says that the 
coverage criteria for Gelsyn-3 have not been met. Our physician reviewer found the Plan requires a trial of 
Orthovisc or Supartz FX before they will approve the requested drug. Our reviewer also found that there is no 
documentation provided indicating that the Plans required drug(s) would likely be less effective and/or likely 
have adverse effects 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 Gelsyn-3 have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Gelsyn-3 (J7328).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device and related supplies to 
be provided by an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve OON services. You say that the enrollee needs to be taught how to use the 
equipment. The Plan denied your request. The Plan says this is available by a provider in the network. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items at issue in this appeal. The records do not show that a device from a 
network provider has been tried and is unable to meet the enrollees needs. We found no exception that would 
require the Plan to pre-approve these OON items. Therefore, we decided that the Plan does not have to pre-
approve a pneumatic compression device and related supplies to be provided by an out-of-network (OON) 
provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intensity-modulated radiation therapy (IMRT) provided from 
March 25, 2022, to March 29, 2022, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for IMRT. You say that you are appealing the denial. The Plan denied your request. 
The Plan says their first decision to deny payment for the service was right. 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 requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for intensity-modulated radiation therapy (IMRT) 
provided from March 25, 2022, to March 29, 2022, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code Q0092 billed for date of service April 8, 
2023.   
You asked the Plan to pay for procedure code Q0092. You say that the claim is billed correctly and should be 
paid. The Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed.  
 
The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code Q0092 is 2. The MAI value for this code is 3. You billed 4 units of this 
code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were 
actually provided, were correctly coded, and were medically necessary. Based on this information, we decided 
that Medicare rules for coverage of procedure code Q0092 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code Q0092 billed for date of service April 8, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 power wheelchair and accessories (K0856, 
E2361, E1028, E1002, K0040, E2613, E0956, E1028, E0955, E1028, E2607). 
 
You asked the Plan to pre-approve a group 3 power wheelchair 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 and 
accessories. Our reviewer says that the services are not medically necessary. Our physician reviewer found the 
group 3 power wheelchair with tilt and recline is not medically necessary per LCD L33789. The enrollee has a 
mobility deficit that impairs MRADLs and cannot be alleviated with a cane, walker, or manual wheelchair due 
to weakness. The enrollee does not perform intermittent catheterization, have spasticity that needs a power 
seating system, or have documentation that supports a high risk of pressure injury. The wheelchair evaluation 
notes no current pressure ulcers, no past pressure ulcers, no flap surgery. The enrollee is unable to perform 
pressure relief. 
 
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 and accessories have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a group 3 power wheelchair and accessories (K0856, E2361, 
E1028, E1002, K0040, E2613, E0956, E1028, E0955, E1028, E2607).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450-26 billed for date of service June 16, 
2023. 
 You asked the Plan to pay for procedure code 70450-26. You say that the claim is billed correctly and should 
be paid. The Plan denied your request. The Plan says payment for code 70450-26 is bundled into payment for 
code 70496. 
 
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 
70450-26 is a column II code to column I code 70496. 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 70450-26 billed for date of service 
June 16, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the face positioning device (E1399) provided June 
2, 2023. 
 
You asked the Plan to reimburse you for the face positioning device . You say that your surgeon explained to 
you that the equipment was medically necessary for your eye to heal well and get the best vision outcome from 
the surgery. The Plan denied your request. The Plan says this is a precautionary device that does not meet the 
definition of durable medical equipment. 
 
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 reimburse you for the face positioning device (E1399) provided June 2, 
2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the si Portfolio Comprehensive Genetic testing panel (81455, 
G0452) provided April 6, 2023. 
 
You asked the Plan to pay for the genetic testing. You say that you are requesting reconsideration of the claim. 
The Plan denied your request. The Plan says the enrollee does not meet the Medicare criteria for coverage. 
 
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. Review of the records show that the enrollee does not have a 
diagnosis of cancer. The claim was billed with diagnosis codes R789.89: other specified abnormal findings of 
blood chemistry and D50.9: iron deficiency anemia, unspecified. The diagnosis codes billed do not support the 
genetic testing. Based on this information, we decided that Medicare rules for coverage of the genetic testing 
have not been met. Therefore, we decided that the Plan does not have to pay for the si Portfolio Comprehensive 
Genetic testing panel (81455, G0452) provided April 6, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 20650 billed for date of service April 10, 
2023. 
 
You asked the Plan to pay for procedure code 20650. You say that this service is documented in the medical 
record and should be paid. The Plan denied your request. The Plan says the billed code is 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 code 20650 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code 20650 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code 20650 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 20650 billed for date of service April 10, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on July 1, 2023 to July 29, 2023. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that these services were 
medically necessary. The Plan denied your request. The Plan says Medicare does not separately pay for ESRD-
related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on July 1, 
2023 to July 29, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 95819, defined as electroencephalogram (EEG); 
including recording awake and asleep, billed on date of service December 30, 2022. 
 
You asked the Plan to pay for 95819. You say that 95819 should be paid as billed because it is supported in the 
documentation and is coded correctly. The Plan denied your request. The Plan says 95819 is denied because it 
was not billed with an appropriate modifier. 
 
The Plan must follow Medicare rules. Medicare rules say that if the same physician or other supplier entity 
does not furnish both the TC and PC of the diagnostic service, the professional interpretation of a diagnostic 
test must be separately billed with modifier -26 by the interpreting physician.  
We looked at the file and Medicare rules. We confirmed that 95819 is a diagnostic service which has a separate 
TC and PC. The enrollee received this diagnostic service during an inpatient hospital stay, therefore, the same 
provider/supplier did not complete both the TC and PC for this service. According to Medicare rules, the 
provider performing the professional interpretation of the diagnostic service provided under arrangement to a 
hospital can bill and be paid for the PC of the service. The PC of a diagnostic service should be documented on 
the claim form with modifier -26. We have confirmed that 95819 was billed without the required modifier -26. 
Based on this information, we decided that Medicare rules for coverage of 95819 have not been met. Therefore, 
we decided that the Plan does not have to pay for code 95819, defined as electroencephalogram (EEG); 
including recording awake and asleep, billed on date of service December 30, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the additional moderate sedation time provided on date of 
service June 7, 2023, billed with code 99153. 
 
You asked the Plan to pay for procedure code 99153. You say that this service was medically necessary. The 
Plan denied your request. The Plan says code 99153 is not payable in the facility setting.  
 
Medicare rules say that the OPPS recognizes that CPT code 99153 is a PE only code and that PE are not 
payable to the physician for services provided in the facility setting.   
We find that payment for CPT code 99153 is not supported. Specifically, there is no separate payment to the 
physician for CPT code 99153 when performed in the facility setting. Therefore, we decided that the Plan does 
not have to pay for the additional moderate sedation time provided on date of service June 7, 2023, billed with 
code 99153.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on March 15, 2022, billed with 
codes 81194, 81275, 81276, 81292, 81295, 81298, 81301, 81311, 81317 and 81321. 
 
You asked the Plan to pay for the genetic testing billed. You say that this testing was 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 
March 15, 2022, billed with codes 81194, 81275, 81276, 81292, 81295, 81298, 81301, 81311, 81317 and 
81321.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 11042, 11045,17000, 17003, and 99349 
billed for date of service July 3, 2023. 
 
You asked the Plan to pay for the billed services. You say that the proper modifiers and diagnosis codes were 
billed. The Plan denied your request. The Plan says the billed codes 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. 
 
We looked at the file and the rules. We find that CPT codes 11042, 11045, 17000, 17003, and 99349 are not 
supported in the medical record. Specifically, the medical records do not include the signature of the treating 
physician 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 codes 
11042, 11045,17000, 17003, and 99349 billed for date of service July 3, 2023.