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

 
We decided that the Plan does not have to pre-approve a Kyphoplasty. 
 
You asked the Plan to pre-approve a Kyphoplasty. You say that a Kyphoplasty is medically necessary. The 
Plan denied your request. The Plan says the requested Kyphoplasty is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a Kyphoplasty is 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 Kyphoplasty. Our reviewer says that 
the requested Kyphoplasty is not considered medically reasonable and necessary in this case. Our physician 
reviewer found that a review of the medical records indicated that you were being treated for back pain. Past 
medical history was positive for hypertension, atherosclerosis of the aorta, atrial fibrillation, osteoporosis, 
lumbar vertebral fracture, thoracic vertebral osteoporotic fracture, gastroesophageal reflux disease, irritable 
bowel syndrome, Parkinson's disease, social anxiety disorder, adjustment disorder with mixed anxiety and 
depressed mood, and bilateral glaucoma. Past orthopedic surgical history was negative. Conservative treatment 
included physical therapy and medications. The September 26, 2022 x-rays of the lumbar spine, as noted on the 
February 14, 2023 exam, have impressions of anterior osteophytes throughout the lumbar spine with 
indentation of the superior endplate of L3 and L5 that were unchanged from the prior exam with interval new 
indentation of the superior endplate of L4 with loss of height of approximately 20%; facet arthropathy of the 
lower lumbar spine is identified; findings are suggestive of progression of degenerative disc disease with new 
compression fracture of L4 since October 16 2020. The treating physicians report of March 1, 2023 cites 
continued back pain that improved with exercise. There are no objective findings noted. Detailed 
documentation is not evident regarding an acute or subacute lumbar fracture. Additionally, there is no 
documentation of a progression of the body height loss, greater than 25% vertebral body height loss, kyphotic 
deformity, or a severe impact on daily activities. Moreover, there are no recent examinations provided to 
corroborate persistent findings. Therefore, the requested Kyphoplasty does 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 Kyphoplasty have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Kyphoplasty.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the definitive urine drug testing, for 15-21 drug classes 
(G0482) provided on October 4, 2022, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the drug testing. You say that kindly process this claim towards payment. 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 definitive urine drug testing, for 15-21 drug 
classes (G0482) provided on October 4, 2022, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81345 billed for date of service March 1, 
2023. 
 
You asked the Plan to pay for procedure code 81345. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says payment for code 81345 is bundled into payment for code 0089U. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 81345 
is a column II code to column I code 0089U. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 81345 billed for date of service March 1, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 51700, 51703, and 99221 rendered from 
December 16, 2022, to December 17, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the records do not support the services 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.  
In this case, the CPT Code Manual definition of the denied codes is: 
 
CPT 51700: 
 
Bladder irrigation, simple, lavage and/or instillation 
 
CPT 51703: 
 
Insertion of temporary indwelling bladder catheter; complicated (eg, altered anatomy, fractured 
catheter/balloon) 
 
CPT 99221: 
 
Initial hospital care, per day, for the evaluation and management of a patient, which requires these 3 key 
components: A detailed or comprehensive history; A detailed or comprehensive examination; and Medical 
decision making that is straightforward or of low complexity. Counseling and/or coordination of care with 
other physicians, other qualified health care professionals, or agencies are provided consistent with the nature 
of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring admission are of 
low severity. Typically, 30 minutes are spent at the bedside and on the patient's hospital floor or unit 
 
In this case, we have confirmed that code 51700 is a column two code to column one code 51703 with a 
modifier indicator of 0. The column two code is therefore not payable. Based on the claim submitted, Medicare 
billing criteria have not been met. 
 
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 for CPT 51703 and CPT 99221. Our reviewer says that the services at 
issue in this case were not supported by the medical records. Our reviewer found that the enrollee had an 
unwitnessed fall and fractured their hip. The documentation provides support for low-level medical decision 
making. The exam is detailed, the history is not detailed/comprehensive. Therefore, CPT 99221 is not 
supported in this case. In terms of CPT 51703, the the records do provide documentation of foley placement 
and bladder irrigation, but there is no documentation of it being complicated, such as because of altered 
anatomy.  
 
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 procedure codes 51700, 51703, and 99221 rendered from December 16, 2022, to December 17, 
2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve placement of an implanted loop recorder (ILR). 
 You asked the Plan to pre-approve the requested ILR procedure. You say that this is medically necessary for 
the enrollee. The Plan denied your request. The Plan says the clinical information provided does not document 
any syncope episodes. 
 
The Plan must follow Medicare rules. Medicare rules say ILR placement may be considered medically 
necessary when it is needed to evaluate syncope that is thought to be cardiac-related but occurs too infrequently 
to be detected by traditional external monitors.  
 
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 requested ILR procedure. Our 
reviewer says that the requested ILR procedure is not medically reasonable and necessary based on NCD 
criteria. Our physician reviewer found the provided documentation does not indicate the enrollee has a history 
of atrial fibrillation, nor were any significant cardiac arrhythmias noted on electrocardiogram (ECG) 
monitoring. A recent randomized clinical trial found that continuous monitoring for atrial fibrillation with an 
ILR (followed by treatment with oral anticoagulation if atrial fibrillation was detected) was not superior to 
usual care in reducing stroke or systemic embolism among patients at high risk of stroke but without a known 
prior history of atrial fibrillation. Therefore, the reviewer found that the requested ILR 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 requested ILR procedure have not been met. Therefore, we decided that the 
Plan does not have to pre-approve placement of an implanted loop recorder (ILR).
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 the enrollee requires stand-by to light touch 
assistance with bed mobility, light touch to moderate assistance with transfers. You also say that they were able 
to ambulate 8 feet with gait belt, walker, moderate assistance and were fatigued with shortness of breath. The 
Plan denied your request. The Plan says based on Medicare guidelines, the IRF services requested do not meet 
the requirements for approval.  
 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 does not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, at an intensive rehabilitation therapy program. There is not a 
reasonable expectation that this individual will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an inpatient rehabilitation facility. The enrollee continues to have a 
need for skilled therapy with ongoing safety concerns and a potential for functional improvement however, the 
documentation doesnt support that they would meet criteria for admission to an acute inpatient rehabilitation 
facility.  There is no indication that the enrollee would require skilled rehabilitation in an IRF, participating in 
rehab services 15 hours a week, under the supervision of a physician with at least 3 visits weekly to regain or 
maintain their functional status.  The enrollee can receive further services at a lower level of care.  
 
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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an attended polysomnography (95810). 
 
You asked the Plan to pre-approve an attended polysomnography. You say that due to the patient's history of 
stroke, the doctor would like this request to be approved. The Plan denied your request. The Plan says this 
request does not meet the definition of medical necessity. 
 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 an attended polysomnography. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the patient can undergo a home sleep study. Our reviewer also found that 
the records do not support that the patient has any medical conditions that would require a sleep study to be 
performed in a lab. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an attended polysomnography have not been met. Therefore, we decided that 
the Plan does not have to pre-approve an attended polysomnography (95810).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (11043, 11046) provided on March 29, 2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services are not 
payable. 
 
The Plan must follow Medicare rules. Medicare rules say that many services within the postoperative period 
are considered to be included within payment for the global surgical procedure. Two exceptions to this are EM 
services unrelated to the surgical procedure, which should be billed with modifier -24, and unrelated surgical 
procedures, which should be billed with modifier -79.  
 
We looked at the file and Medicare rules. The service at issue (11043) is within the global surgery period of 
code 14041 provided on March 22, 2023. We find that the service at issue may be unrelated to the surgical 
procedure; however, the required modifier to indicate this was not used. As such, the billing rules for these 
services have not been met. 
 
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 11046 is an add-on code and has not been 
billed with a payable primary procedure code. Based on the claim submitted, Medicare billing criteria have not 
been met. Therefore, we decided that the Plan does not have to pay for the services (11043, 11046) provided on 
March 29, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on April 14, 2023, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the services were 
not authorized. 
 
Medicare rules say that plans can require enrollees to get authorized prior to receiving services. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for the lab services provided on April 14, 2023, by an out-of-
network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a MyoPro orthotic device (L8702). 
 
You asked the Plan to pre-approve a MyoPro orthotic device. You say that the MyoPro is supported as an 
appropriate intervention and is reasonably and medically necessary as recognized by medical communities and 
key opinion leaders in rehabilitation. The Plan denied your request. The Plan says the clinical value and 
effectiveness of MyoPro orthotic device in the setting of cerebrovascular accident 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 MyoPro orthotic device. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the MyoPro Orthosis is not known to be effective, based on scientific evidence, 
professional standards and expert opinion, in improving health outcomes. The MyoPro is not the standard of 
care for this patient's condition or in widespread use for this patient's condition based on scientific evidence. 
Our reviewer found that there is insufficient evidence in the literature that the MyoPro Orthosis will improve 
the long-term outcomes for this patient. Our physician reviewer also found that there is insufficient evidence in 
the literature that this device will increase participation in bimanual activities. 
 
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 MyoPro orthotic device have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a MyoPro orthotic device (L8702).
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 you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says the records show that the enrollee does not meet 
Medicare  guidelines fore services in an IRF.  
 
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 complexity of the enrollees nursing, medical, and rehabilitation needs does not 
require an acute rehabilitation hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, at an intensive rehabilitation therapy program. The enrollee continues to have a need for skilled 
therapy with ongoing safety concerns and a potential for functional improvement. However, the documentation 
does not support that the enrollee would meet criteria for admission to an IRF.  There is no indication that the 
member would require skilled rehabilitation in an IRF, participating in rehabilitation services 15 hours a week, 
under the supervision of a physician with at least 3 visits weekly to regain or maintain theii functional 
status.  The enrollee can receive further services at a lower level of care.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel rendered on 
July 26, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that a urine PCR panel cannot be unbundled and billed as 
individual components. 
 
We looked at the file and Medicare rules. The file shows that the urine PCR panel was not billed as a single 
unit of service. 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 the urine polymerase chain reaction 
(PCR) panel rendered on July 26, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve kyphoplasty (22514). 
 
You asked the Plan to pre-approve kyphoplasty. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not medically necessary because your records show you do not have an acute or 
subacute fracture based on symptom onset or advanced imaging and you do not have a history of osteoporosis. 
 
The Plan follows Medicare rules. Medicare rules say that kyphoplasty can be 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 kyphoplasty. Our reviewer says that 
you do not meet criteria for coverage. Our physician reviewer found detailed documentation is not evident 
regarding acute or subacute lumbar fractures. Additionally, there is no documentation of a progression of the 
body height loss, greater than 25% vertebral body height loss, kyphotic deformity, or a severe impact on daily 
activities. Moreover, there is magnetic resonance imaging (MRI) corroboration of other plausible causes of 
pain. 
 
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 (22514).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex device (22869). 
 
You asked the Plan to pre-approve the Vertiflex device. You say that this is medically necessary. The Plan 
denied your request. The Plan says  this device has not been shown to be safe and effective for treatment of the 
enrollee's condition. 
 
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 Vertiflex device. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the Vertiflex device 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 the Vertiflex device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Vertiflex device (22869).