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

 
We decided that the Plan does not have to pre-approve percutaneous laminectomy at L4-5 (0275T). 
 
You asked the Plan to pre-approve percutaneous laminectomy at L4-5. 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 percutaneous laminectomy at L4-5. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found there is no compelling rationale presented or extenuating circumstances 
noted to support the medical necessity of this request as an exception. Therefore, the requested percutaneous 
laminectomy at L4-5 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 percutaneous laminectomy at L4-5 have not been met. Therefore, we decided 
that the Plan does not have to pre-approve percutaneous laminectomy at L4-5 (0275T).
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 are requesting a fast appeal for the denial of an 
IRF admission. The Plan denied your request. The Plan says the enrollee does not meet Medicare guidelines for 
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 enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 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.  
 
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: 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 is highly motivated to participate in 
therapy with the goal of returning to prior level of function and preventing further falls which may lead to 
injury or acute care admission. The Plan denied your request. The Plan says the enrollee does not meet 
Medicare guidelines for 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 enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 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.  
 
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: 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 are requesting reconsideration for the denial of 
an IRF admission based on medical necessity. The Plan denied your request. The Plan says 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 complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 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.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nervous system function test and the office visit provided 
on April 20, 2023, by an OON provider.  
 
You asked the Plan to pay for the nervous system function test and the office visit. You say that you are 
requesting reconsideration of the denied claim. The Plan denied your request. The Plan says the service was not 
authorized. 
 
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 Plan contract says the enrollees POS benefit only applies to 
covered routine dental services. 
 
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 nervous system function test and the office 
visit provided on April 20, 2023, by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the electronic connection between wheelchair controller 
and two or more power seating system motors (E2311). 
 
You asked the Plan to pre-approve the electronic connection. You say that this is the least costly way to run the 
legs on this chair. The Plan denied your request. The Plan says there is no medical need to control the requested 
power options through the joystick. 
 
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 electronic connection. Our reviewer 
says that the requested item is not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee has spastic quadriplegia and 4/5 strength in upper extremities. The enrollee's range 
of motion in upper extremities is functional.   
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 electronic connection have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the electronic connection between wheelchair controller and two or more 
power seating system motors (E2311).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76881 billed for date of service August 13, 
2021. 
 
You asked the Plan to pay for procedure code 76881. You say that the medical records support the procedures 
billed. The Plan denied your request. The Plan says payment for code 76881 is bundled into payment for code 
20611. 
 
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 76881 
is a column II code to column I code 20611. 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 76881 billed for date of service August 13, 2021.
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 would benefit from short term IRF rehab 
to improve functional mobility, ADLs, and gait to reduce acute care hospital readmission and caregiver burden. 
The Plan denied your request. The Plan says the enrollee's records do not show complex rehabilitation needs 
that require frequent evaluation by a rehabilitation physician. The Plan says that the services needed may be 
provided safely in a lower level of care.  
 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 enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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: 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's admission is medically necessary and 
appropriate for their recovery and overall well-being. The Plan denied your request. The Plan says the enrollee 
does not meet the criteria for admission to 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 enrollee does not require treatment by multiple therapies. While the medical 
record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different 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 procedure codes U0003 and U0005 billed for date of service 
April 18, 2023. 
 
You asked the Plan to pay for procedure codes U0003 and U0005. You say that you have billed the services at 
issue correctly. The Plan denied your request. The Plan says the provided 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 code U0003 is: Infectious agent detection by nucleic acid (dna 
or rna); severe acute respiratory syndrome coronavirus 2 (sars-cov-2) (coronavirus disease [covid-19]), 
amplified probe technique, making use of high throughput technologies as described by cms-2020-01-r. The 
definition of code U0005 is: Infectious agent detection by nucleic acid (dna or rna); severe acute respiratory syndrome coronavirus 2 (sars-cov-2) (coronavirus disease [covid-19]), amplified probe technique, cdc or non-
cdc, making use of high throughput technologies, completed within 2 calendar days from date of specimen 
collection (list separately in addition to either hcpcs code u0003 or u0004) as described by cms-2020-01-r2. 
 
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 procedure codes U0003 and U0005. Our reviewer says that 
procedure codes U0003 and U0005 do not meet criteria for payment. Our reviewer found that based on the 
medical records provided, there is no documentation that fully supports procedure codes U0003 and U0005. 
The provided records in this case do not document that high throughput technology was used in this case, as is 
required for reimbursement for these codes.  
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure codes U0003 and U0005 have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure codes U0003 and U0005 billed for date of service April 18, 
2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 10035 and 19285 billed for date of service 
April 20, 2023. 
 
You asked the Plan to pay for 10035 and 19285. You say that 10035 and 19285 should be paid as billed 
because the enrollee had multiple procedures on the same date of service. The Plan denied your request. The 
Plan says 10035 is denied because this procedure was billed without an anatomical modifier. 19825 is denied 
because payment for this service would be bundled into payment for 10035. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. The rules also say CPT/HCPCS codes 
describing services performed on anatomic structures that can be distinguished as left or right require laterality 
modifiers.  
 
We looked at the file and Medicare rules. In this case, we have confirmed that code 19285 is a column II code 
to column I code 10035. This claim has not been billed with an appropriate modifier to bypass the edit. We 
have confirmed code 10035, defined as placement of soft tissue localization device(s) (clip, metallic pellet, 
wire/needle, radioactive seeds), percutaneous, including imaging guidance; first lesion, was billed without a 
modifier. Records indicate 10035 was performed on an anatomic structure that can be distinguished as left or 
right. Therefore, a modifier indicating laterality is required. Based on this information, we decided that 
Medicare rules for coverage of 10035 and 19285 have not been met. Therefore, we decided that the Plan does 
not have to pay for procedure codes 10035 and 19285 billed for date of service April 20, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 64445, 64447, and 76942 rendered on 
September 6, 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 denied codes remain not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 In this case, the CPT Code Manual definition of the denied codes is: 
 
CPT 64445: 
 
Injection(s), anesthetic agent(s) and/or steroid; sciatic nerve, including imaging guidance, when performed 
 
CPT 64447: 
 
Injection(s), anesthetic agent(s) and/or steroid; femoral nerve, including imaging guidance, when performed 
 
CPT 76942: 
 
Ultrasonic guidance for needle placement (eg, biopsy, aspiration, injection, localization device), imaging 
supervision and interpretation 
 
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 services at issue in 
this case were not supported by the medical records. Our reviewer found that the medical records do not 
include sufficient documentation to confirm CPT 76942. The ultrasound was not documented with images 
saved. 
 
In terms of CPT 64445 and CPT 64447, the provider reported these codes with modifier XU, for unusual non-
overlapping services. The procedure report does not include documentation to support this modifier. Per 
Medicare Global Surgery rules, the physician performing an operative procedure is responsible for treating 
postoperative pain. Treatment of postoperative pain by the operating physician is not separately reportable. 
 
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 64445, 64447, and 76942 rendered on September 6, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code E0781 for date of service April 16, 2023. 
 
You asked the Plan to pay for code E0781. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the item is not payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that rentals billed with modifier RR, must also be 
billed with a monthly modifier. 
 
We looked at the file and Medicare rules. Review of the file shows that code E0781 was billed with the RR and 
KX modifiers. A required monthly modifier (KH, KI, or KJ) was not billed to indicate the month of rental for 
which reimbursement is being requested. Without this required modifier, this code cannot be paid as billed. 
Based on this information, we decided that Medicare rules for coverage of code E0781 have not been met. 
Therefore, we decided that the Plan does not have to pay for code E0781 for date of service April 16, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the local anesthesia in conjunction with operative or surgical 
procedures (D9215) provided on April 21, 2023. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says this service is not a covered benefit.  
  
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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the service provided is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the local 
anesthesia in conjunction with operative or surgical procedures (D9215) provided on April 21, 2023.
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 the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that percutaneous vertebroplasty and percutaneous 
vertebral augmentation (PVA or Kyphoplasty) procedures will be considered medically reasonable and 
necessary for certain indications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve kyphoplasty. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found detailed documentation is not evident 
regarding the worsening of pain. Additionally, there is no documentation of a progression of the body height 
loss, greater than 25% (on the most recent magnetic resonance imaging (MRI)) vertebral body height loss, 
kyphotic deformity, or a severe impact on daily activities. Moreover, there is MRI corroboration of retropulsion 
and other plausible causes of pain. Therefore, the enrollee does not meet the coverage criteria detailed in the 
LCD. 
 
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).