Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 2 home health physical therapy visits.  
You asked the Plan to pre-approve 2 home health physical therapy visits. You say that you would like to 
request reconsideration of the denied claim and that the services requested are medically necessary. 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 services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found the 
documentation doesnt support that the enrollee requires additional skilled rehab services to provide treatment 
that is 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 home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 2 home health physical therapy visits.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Infuse BMP allograft (20931). 
 
You asked the Plan to pre-approve the Infuse BMP allograft. You say that this is medically necessary. The Plan 
denied your request. The Plan says there is insufficient reliable evidence in the form of high-quality peer-
reviewed medical literature to establish the safety and efficacy of the requested product for use in TLIF. 
 
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 Infuse BMP allograft. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is limited published, large-scale, long-term peer-reviewed literature that shows 
this 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. 
 
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 Infuse BMP allograft have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the Infuse BMP allograft (20931).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Mastopexy (19316). 
 
You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of the 
requested service.  
 
The Plan follows Medicare rules. Medicare rules say that reconstructive surgery is performed on abnormal 
structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or 
disease. It is generally performed to improve function but may also be done to approximate a normal 
appearance. 
 
  
 
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 this service. Our reviewer says that the 
enrollee does not meet criteria for coverage of the requested service. Our physician reviewer found that in this 
case, the record provided is insufficient to establish that the requested service is being performed on abnormal 
structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, 
disease, or to improve function. The elements of the coverage criteria are not satisfied. The requested service is 
not recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Mastopexy (19316).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Fungal PCR panel (87801-59, 87798-XU x13, 87481-59 
x5) provided on May 9, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the laboratory service. You say that please see the attached medical records and 
laboratory report for review and reconsideration. The Plan denied your request. The Plan says enrollees must 
receive their medical services from an in-network provider with the exception being urgent or emergent 
services. Non-emergent services with non-contracted providers require prior authorization before services 
being rendered. 
 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 the Fungal PCR panel (87801-59, 87798-XU x13, 
87481-59 x5) provided on May 9, 2023, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for procedure code G0481 billed for date of service July 12, 2023. 
 
You asked the Plan to pay for the billed service. The Plan denied your request. The Plan says that payment for 
code G0481 is bundled into payment for code 80307. 
 
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. The PTP edit for code pair 80307 and G0481 were withdrawn retroactive to 
July 1, 2023. Based on this information, we decided that Medicare rules for coverage of the billed service have 
been met. Therefore, we decided that the Plan has to pay for procedure code G0481 billed for date of service 
July 12, 2023.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a vacuum assisted socket system (VASS) (L5781). 
 
You asked the Plan to pre-approve a VASS. 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 VASS. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found based on the medical records provided there is no documentation that the VASS at issue in this 
case meets all Medicare criteria for medically reasonable and necessary for the enrollee. Provided records from 
the treating physician in this case document "Extremities: normal extremity with no clubbing, cyanosis or edema." Although there is a notation in the physician's October5, 2023 progress note stating necessity of the 
vacuum system, there are no other historical or examination details of edema or excessive perspiration 
supporting this request. Records document no edema or excessive perspiration on examination of the enrollee's 
left stump and the physician's records reports no edema or excessive perspiration or other features in the history 
to support the request. 
 
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 VASS have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a vacuum assisted socket system (VASS) (L5781).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve computer-assisted surgical navigational procedure for 
musculoskeletal procedures. 
 
You asked the Plan to pre-approve the robot-assisted surgical navigation. You say that the enrollee is in 
extreme pain. You say that they are unable to perform daily activities including bathing and feeding. The Plan 
denied your request. The Plan says the clinical value and effectiveness of computer-assisted surgical navigation 
in conjunction with total shoulder arthroplasty 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 robot-assisted surgical navigation. 
Our reviewer says that the requested robot-assisted surgical navigation is not considered medically reasonable 
and necessary in this case. Our physician reviewer found there are no large volume, long-term/high-quality 
clinical studies that confirm the clinical benefits (ultimate outcomes of functional improvement and pain 
reduction) of computer-assisted surgery over standard surgical approaches in total shoulder arthroplasty. There 
is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this 
request as an exception. Therefore, the requested computer-assisted surgical navigational procedure 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 robot-assisted surgical navigation have not been met. Therefore, we decided 
that the Plan does not have to pre-approve computer-assisted surgical navigational procedure for 
musculoskeletal procedures.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Guardant360 CDx testing (81479) provided on July 24, 
2023. 
 
You asked the Plan to pay for Guardant360 CDx testing. You say that this test was necessary and is supported 
in the medical record. 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 shows that a unique identifier was reported; 
however, the unique identifier does not match the test provided in this case. The unique identifier reported 
(ZB1CW) is used to report the Guardant360 test, which should also be reported with procedure code 0326U. 
However, the medical records provided indicate that Guardant360 CDx testing was requested and performed, 
which is a different test from Guardant360. Based on this information, we decided that Medicare rules for 
coverage of Guardant360 CDx testing have not been met. Therefore, we decided that the Plan does not have to 
pay for Guardant360 CDx testing (81479) provided on July 24, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on March 15, 2023, billed with 
codes 87481, 87491, 87563, 87640, 87653, 87798, 87641, and 87500. 
 
You asked the Plan to pay for the genetic testing billed. You say that the codes are approved by Medicare. 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. Medicare rules say that for tests for infectious agents, a single laboratory 
procedure shall be reported as one unit of service whether it generates one or multiple results. Multiple codes 
should only be used when multiple procedures, multiple methodologies, or multiple test kits are medically 
necessary and used to perform the test.  
 
We looked at the file and Medicare rules. The documentation supports that this panel used the nucleic acid 
probe technique. There is no evidence that multiple procedures, multiple methodologies, or multiple kits were 
used in this case. As such, a single code with one unit of service should be used. Based on this information, we 
decided that Medicare rules for coverage of the testing panel have not been met. Therefore, we decided that the 
Plan does not have to pay for the genetic testing provided on March 15, 2023, billed with codes 87481, 87491, 
87563, 87640, 87653, 87798, 87641, and 87500.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone marrow aspirate. 
 
You asked the Plan to pre-approve the bone marrow aspirate. You say that you were not aware that this was 
fully denied. You say that as a result you did not know that you needed to submit an appeal. You also say that 
you will have completed six weeks of physical therapy as of November 24, 2023. 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 shown. 
 
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 requested bone marrow aspirate is not considered medically reasonable and necessary in this case. 
Our physician reviewer found bone marrow aspirate is experimental. The reviewer found that more research is 
needed to show safety and efficacy when used as bone graft material. Therefore, the reviewer found that the 
request for 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 bone marrow aspirate.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab panel provided on July 31, 2023. 
 
You asked the Plan to pay for the panel. The Plan denied your request. The Plan says there is a more 
appropriate code for the billed services. 
 
The Plan must follow Medicare rules. Medicare rules say that for tests for infectious agents, a single laboratory 
procedure shall be reported as one unit of service whether it generates one or multiple results. Multiple codes 
should only be used when multiple procedures, multiple methodologies, or multiple test kits are medically 
necessary and used to perform the test.  
 
We looked at the file and Medicare rules. The documentation supports that this panel used the nucleic acid probe technique. There is no evidence that multiple procedures, multiple methodologies, or multiple kits were 
used in this case. As such, a single code with one unit of service should be used. Based on this information, we 
decided that Medicare rules for coverage of the testing panel have not been met. Therefore, we decided that the 
Plan does not have to pay for the lab panel provided on July 31, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom G6 continuous glucose monitor (CGM).  
You asked the Plan to pre-approve CGM. You say that the enrollee has tried and failed a Freestyle device. The 
Plan denied your request. The Plan says the enrollee is not on insulin and does not have a history of 
problematic hypoglycemia. 
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 CGM. Our reviewer says that the 
enrollee does not meet criteria for this device. Our physician reviewer found the record does not indicate that 
the enrollee is being treated with insulin or has problematic hypoglycemia. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of CGM have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a Dexcom G6 continuous glucose monitor (CGM).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a false tooth (D6240) and glass caps (D6750). 
 
You asked the Plan to pre-approve dental services. You say that your dentist is looking for a more permanent 
fix. The Plan denied your request. The Plan says there is no evidence showing that dentures could not work. 
 
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. The Plan covers dental 
services when the services are medically necessary and reasonable.  
 
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 dental services. Our reviewer says that 
you do not meet criteria for these services. Our physician reviewer found if there is an existing bridge with damage or decay, a replacement bridge would be necessary. A partial denture would not be a good option for 
replacing a damaged bridge. From the X-Ray submitted, the fractured area of the bridge cannot be seen. In 
order to determine medical necessity, X-Rays that capture the whole bridge and all structures of teeth 18 and 20 
are needed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of dental services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a false tooth (D6240) and glass caps (D6750).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (81209, 81218) provided on February 3, 2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed services are 
not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the use of codes 81209 
and 81218 is not supported by the records provided. Our reviewer found that the laboratory report documents 
date of service March 3, 2023, however these services were billed with date of service February 3, 2023. The 
billed services cannot be verified. 
 We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for the services (81209, 81218) provided on February 3, 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 
(E0955, E1002, E1012, E1028, E2311, E2361, E2603, E2620, K0108, K0856). 
 
You asked the Plan to pre-approve a group 3 power wheelchair with single power option. 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. Our reviewer says that the services are not medically necessary. Our physician reviewer found 
based on the medical records provided there is no documentation that the group 3 power wheelchair with single 
power option and a power tilt feature at issue in this case meets all Medicare criteria for medically reasonable 
and necessary for the enrollee. Provided records do not support that the enrollee is high risk for skin 
breakdown, has a history of pressure ulcer(s) or has had skin flap surgery. Provided records indicate the 
enrollee is moderate risk for skin breakdown; the enrollee is able to walk about 20 feet. Records do not 
document the enrollee performs bladder self-catheterization or that the enrollee has increased muscle tone or 
spasticity to meet criteria for the power tilt feature and thus the single power option base. 
 
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 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 (E0955, E1002, E1012, E1028, E2311, E2361, E2603, E2620, K0108, K0856).