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

 
We decided that the Plan does not have to pay for procedure code 49591 billed for date of service February 8, 
2023. 
 
You asked the Plan to pay for the billed services. You say that the operative report is very detailed on both 
surgical services. The Plan denied your request. The Plan says the code is included in the main procedure. 
 
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the 
service billed with the modifier indicates a distinct procedural service.   

The medical records provided do not show that code 49591, billed with the -59 modifier, was a distinct 
procedural service. Based on this information, we decided that Medicare rules for coverage of services billed 
with a -59 modifier have not been met.  Therefore, we decided that the Plan does not have to pay for procedure 
code 49591 billed for date of service February 8, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services billed with code 81479 provided on 
September 22, 2022, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the laboratory services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services provided are not a covered benefit. 
 
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.  
 
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 laboratory services have not been met.  
 
The Plan has network providers available who can provide the items/services at issue in this appeal. We found 
no exception that would require the Plan to pay for the laboratory services. Therefore, we decided that the Plan 
does not have to pay for the laboratory services billed with code 81479 provided on September 22, 2022, by an 
out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee requires and can benefit from an 
interdisciplinary team approach. The Plan denied your request. The Plan says an IRF admission is not 
medically necessary, and the enrollee's needs can be met at 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 that the enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. 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 IRF admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Balloon Dilation of the Eustachian tube (BDET) 
procedure. 
 
You asked the Plan to pre-approve a BDET procedure. You say that this procedure is medically necessary. The 
Plan denied your request. The Plan says this procedure is considered investigational.  
 
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 BDET procedure. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that in this case, the record indicates that the enrollee has Eustachian tube 
dysfunction. There is insufficient literature to support the safety and efficacy, as defined by Medicare rules, of 
the requested service. The record provided does not establish the medical necessity and reasonableness, as defined by Medicare rules, of the requested service. The elements of the coverage criteria are not satisfied.  
 
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 BDET procedure have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a Balloon Dilation of the Eustachian tube (BDET) procedure.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 0339U for date of service February 1, 2023. 
 
You asked the Plan to pay for procedure codes 0339U. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services are not payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 0339U is oncology (prostate), mRNA expression 
profiling of HOXC6 and DLX1, reverse transcription polymerase chain reaction (RT-PCR), first-void urine 
following digital rectal examination, algorithm reported as probability of high-grade cancer. 
 
We find that CPT code 0339U is not supported in the medical record. Specifically, this code was billed with 
diagnosis codes 29.1 (Benign neoplasm of prostate) and N40.0 (Benign prostatic hyperplasia without lower 
urinary tract symptoms). These diagnosis codes should not be billed together. This means the claim is not payable as billed. Based on this information, we decided that Medicare rules for coverage of procedure codes 
0339U have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 0339U 
for date of service February 1, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SeaSpine Osteo Current Allograft. 
 
You asked the Plan to pre-approve SeaSpine Osteo Current Allograft. You did not provide a specific argument 
with your appeal request. The Plan denied your request. The Plan says it has approved cervical spine cage 
surgery and hospitalization. However, the Plan has denied authorization for SeaSpine Osteo Current Allograft. 
The Plan says that medical studies have not proven that the use of this product during spine surgery is better 
than standard Allograft products. 
 
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 SeaSpine Osteo Current 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 request to be an effective and/or safe treatment for the noted pathology. Further studies are 
needed to corroborate that the requested allograft would be as safe or better than standard allograft procedures. 
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 SeaSpine Osteo Current Allograft have not been met. Therefore, we decided 
that the Plan does not have to pre-approve SeaSpine Osteo Current Allograft.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99153 billed for date of service November 7, 
22. 
 
You asked the Plan to pay for the billed services. 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.  
 
The file shows that code 99153 was provided in an outpatient hospital place of service. We find that payment 
for 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 
procedure code 99153 billed for date of service November 7, 22.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous tibial nerve stimulation (PTNS). 
 
You asked the Plan to pre-approve PTNS treatment. You say that the enrollee has tried and failed several 
medications. The Plan denied your request. The Plan says this is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve PTNS treatment. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found PTNS is not indicated for patients with symptoms due to underlying neurologic conditions. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of PTNS treatment have not been met. Therefore, we decided that the Plan does 
not have to pre-approve percutaneous tibial nerve stimulation (PTNS).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for insertion of intrauterine device and removal of intrauterine 
device. 
 
You asked the Plan to pay for insertion of intrauterine device and removal of intrauterine device. You say that 
insertion of intrauterine device and removal of intrauterine device is medically necessary. The Plan denied your 
request. The Plan says insertion of intrauterine device and removal of intrauterine device is not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that items/services for the purposes of preventing 
conception (contraception) are not considered medically reasonable and necessary.  
 
Records show that the requested service is primarily for the purpose of contraception. The documentation does not show that this service is being requested to treat a specific illness/injury. As such, the Medicare rules for 
coverage of this service have not been met. Therefore, we decided that the Plan does not have to pay for 
insertion of intrauterine device and removal of intrauterine device.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (70554) provided on December 14, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the claim is not 
payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that payment for CPT code 70554 is not supported in the medical record. Specifically, code 70554 has 
a bilateral procedure indicator of 3. As such, when this service is performed bilaterally, the code should be 
billed on one line with two units of service, or with the appropriate modifiers LT/RT/50. Code 70554 was not 
billed appropriately in this case. 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 (70554) 
provided on December 14, 2022.
Appeal type: Lab
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 October 18, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that you disagree with the Plan's 
denial. 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 October 
18, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve insertion of interlaminar/interspinous process 
stabilization/distraction device (22869). 
 
You asked the Plan to pre-approve insertion of interlaminar/interspinous process stabilization/distraction 
device. You say that this procedure is medically necessary and appropriate for this enrollee. The Plan denied 
your request. The Plan says this device/surgery is not indicated for this enrollee given multi-level disease. 
 
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 insertion of interlaminar/interspinous 
process stabilization/distraction device. Our reviewer says that the requested items/services are not considered 
medically reasonable and necessary in this case. Our physician reviewer found  
 that current evidence-based medical guidelines and peer reviewed literature do not fully support the spinal 
decompression device procedure over the gold standard of lumbar laminectomy. There is a lack of large 
volume, long-term peer-reviewed outcome studies to support the use of this device for this enrollees medical 
condition as discussed above. FDA indications include implantation of the Superion device at one or two 
adjacent lumbar levels in patients with moderate spinal stenosis in whom operative treatment is indicated at no 
more than two levels, from L1 to L5. This enrollee has multiple degrees of spinal stenosis, many not at FDA 
indicated levels of moderate spinal stenosis including the planned level of implantation of L4-5. FDA 
contraindications include spinal instability, scoliosis, obesity, and osteoporosis, and have not been adequately 
addressed in the medical records. There is no discussion of spinal instability on flexion/extension films. There 
is imaging evidence of mild levocurvature of the lumbar spine with no documentation of the Cobb angle. There 
is no discussion indicating that a dual x-ray absorptiometry (DEXA) scan has demonstrated the lack of 
significant osteoporosis in this enrollee. There is no compelling rationale presented or extenuating 
circumstances noted to support the medical necessity of this request as an exception. Therefore, the requested 
Vertiflex Superion interspinous spacer at L4-5, in this case, 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 insertion of interlaminar/interspinous process stabilization/distraction device 
have not been met. Therefore, we decided that the Plan does not have to pre-approve insertion of 
interlaminar/interspinous process stabilization/distraction device (22869).
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve Matrion and DermACELL wound products (15271, Q4122, 
Q4201).  
 
You asked the Plan to pre-approve Matrion and DermACELL wound products. You say that these supplies are 
medically necessary. The Plan denied your request. The Plan says that there are not enough studies on Matrion 
and DermACELL to show it is safe and effective.  
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Matrion and DermACELL wound 
products. Our reviewer says that the requested items/services are considered medically reasonable and 
necessary in this case. Our physician reviewer found that there is a need for products like Matrion and 
DermACELL in this enrollee to accelerate safe and effective wound closure. This is based on community 
standards. Matrion is the first decellularized, full-thickness placental membrane designed to act as a protective 
barrier to support wound healing. DermACELL is a human acellular dermal matrix (ADM) that serves as a 
scaffold to reinforce damaged or inadequate soft tissue during wound healing.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Matrion and DermACELL wound products have been met. Therefore, we 
decided that the Plan has to pre-approve Matrion and DermACELL wound products (15271, Q4122, Q4201).   
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) (64625) for sacroiliac 
dysfunction. 
 
You asked the Plan to pre-approve RFA for sacroiliac dysfunction. You say that this procedure is medically 
necessary and appropriate. The Plan denied your request. The Plan says this service is not covered to treat pain 
in the joint that connects the pelvis to the tailbone (sacroiliac pain). 
 
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 RFA for sacroiliac dysfunction. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found that the documentation provided is not evident regarding imaging or 
radiographic evidence supporting the pathology of the bilateral sacroiliac joints. Additionally, multiple other plausible pain generators including at the lumbosacral spine are evident. 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, requested service in this case 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 RFA for sacroiliac dysfunction have not been met. Therefore, we decided that 
the Plan does not have to pre-approve radiofrequency ablation (RFA) (64625) for sacroiliac dysfunction.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a clitoral hood reconstruction procedure. 
 
You asked the Plan to pre-approve the surgery. You say that this is medically necessary. The Plan denied your 
request. The Plan says this surgery will not repair accidental injury or improve the function of an abnormal 
body part. 
 
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 surgery. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the the record indicates that the enrollee has gender dysphoria and has undergone vaginoplasty.  The 
record provided does not establish the medical necessity of the requested service. The record provided does not establish the medical necessity and reasonableness, as defined by Medicare rules, of the requested service. The 
elements of the coverage criteria are not satisfied. 
 
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 surgery have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a clitoral hood reconstruction procedure.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a manual wheelchair. 
 
You asked the Plan to pre-approve manual wheelchair. You say that the enrollee's current wheelchair is very 
heavy to transport around. The Plan denied your request. The Plan says the enrollee has a current manual 
wheelchair that is still within its reasonable useful lifetime. 
 
The Plan must follow Medicare rules. Medicare rules say that replacement of durable medical equipment 
(DME) is not covered during the reasonable useful lifetime of the equipment.  
 
We looked at the file and Medicare rules. The enrollees current wheelchair was obtained in September 2018; 
therefore, this item is still within its reasonable useful lifetime. Based on this information, we decided that 
Medicare rules for coverage of manual wheelchair have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a manual wheelchair.