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

 
We decided that the Plan has to pay for procedure code 27350 rendered on June 1, 2023. 
 
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 that 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 
code 27350 is "Patellectomy or hemipatellectomy." 
 
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 supported by the medical records. Our reviewer found that the procedure details cites a 
comminuted patella fracture was then able to be visualized. Hemarthrosis was evacuated from the knee. There 
were gouty tophi seen within the knee joint. These were evacuated. The knee joint was irrigated. An excisional 
debridement of the quadriceps tendon ends and patella fragments was performed, along with excision of 
extensive tophi. Therefore, documentation does support CPT 27350: patellectomy or hemipatellectomy as a 
separate and distinct procedure from CPT 27339: excision procedures on the femur and knee joint. 
 
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 been met. Therefore, we decided that the Plan has to pay for 
procedure code 27350 rendered on June 1, 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the LTACH services are medically 
necessary. The Plan denied your request. The Plan says the LTACH services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee does not require services at the LTACH that are not already 
available at the current facility provided by the health Plan. The documentation provided does not indicate that 
LTACH services are 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the implantation of a UroLift system. 
 
You asked the Plan to pre-approve the UroLift system. You say that the enrollee has tried and failed 
Tamsulosin. 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 the UroLift system. Our reviewer says 
that the requested UroLift system is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the records do not show that the enrollee has moderate to severe benign prostatic 
hyperplasia (BPH) defined as an American Urological Association (AUA) symptom score above 7 including 
signs of obstruction, such as increased voiding symptoms or decreased peak urinary flow rate (i.e., The 
individual has a peak urine flow rate (Qmax) less than 15 ml/sec on a voided volume that is greater than 125 ml), is refractory to or intolerant of usual BPH medication, and has a prostatic volume less than or equal to 80 
milliliters (ml). Therefore, the reviewer found that the requested UroLift system 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 UroLift system have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the implantation of a UroLift system.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee needs LTACH to regain 
maximum level of functioning. The Plan denied your request. The Plan says the enrollee can continue receiving 
this care in the hospital or in a lower acuity setting. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee does not require services at the LTACH that are not already available at 
the current facility. Transfer to the LTACH is not medically necessary as it would not be clinically 
advantageous at this time. Completion of treatment at the current facility is 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve repair of nasal valve collapse (30469), excision or 
destruction of intranasal lesion (30117), and ablation (30801). 
 
You asked the Plan to pre-approve the VivAer procedure. You say that Original Medicare covers nasal airway 
remodeling using the requested codes. The Plan denied your request. The Plan says the documentation does not 
support that the enrollee meets the indications for this procedure and are free of contraindications for this 
procedure. 
 
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 VivAer procedure. Our reviewer 
says that the requested VivAer procedure is not considered medically reasonable and necessary in this case. 
Our physician reviewer found the record indicates that the enrollee has nasal obstruction, congestion, and sinusitis. There is insufficient literature to support the safety and efficacy of the requested service for the 
enrollee's specific conditions. The record provided does not establish the medical necessity and reasonableness, 
as defined by Medicare rules, of the requested service. Therefore, the reviewer found that the requested VivAer 
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 VivAer procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve repair of nasal valve collapse (30469), excision or destruction of intranasal lesion 
(30117), and ablation (30801).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 88305, 88341, and 88342 billed for date of 
service April 14, 2023. 
 
You asked the Plan to pay for procedure codes 88305, 88341, and 88342. You say that the report supports the 
services billed. The Plan denied your request. The Plan says this code is included in the facility payment and is 
not separately payable.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that the specimen was taken while the enrollee was in a skilled nursing facility. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 1 for CPT codes 88305, 88341, and 
88342. This means there is both a professional and technical component for the CPT codes. In this case, an 
appropriate modifier has not been billed. Based on this information, we decided that Medicare rules for 
coverage have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 
88305, 88341, and 88342 billed for date of service April 14, 2023.
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pay for continuous intraoperative neurophysiology monitoring rendered on July 
11, 2023. 
 
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says that this was experimental. 
 
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 pay for the services. Our reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found that neuromonitoring has become common during many surgical procedures, and it has generally 
replaced intraoperative wake-up testing during spine surgery. Neuromonitoring is performed by a specialized 
team with specific expertise in the techniques that are used. In most instances, no "standard of care" exists for 
intraoperative neuromonitoring, and techniques are chosen by the surgeon and monitoring team in order to 
assess or protect structures at risk. Somatosensory evoked potentials (SSEP) is one of the most commonly used 
evoked potential monitoring modalities in the operating room. SSEPs are used in a variety of spine, 
intracranial, endovascular, and cardiovascular surgeries, including lumbar spine surgery. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have been met. Therefore, we decided that the Plan has to pay for 
continuous intraoperative neurophysiology monitoring rendered on July 11, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Tempus Gene Panel (81455) provided on May 12, 2023, by 
an out-of-network (OON) provider.  
 
You asked the Plan to pay for the laboratory service. You say that denial of this claim based on failure to obtain 
prior authorization is not justifiable in this instance. 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 Tempus Gene Panel (81455) provided on May 12, 
2023, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to pay for procedure codes 17000 and 17003. We decided that the Plan does not 
have to pay for procedure code 99213.  
 
You asked the Plan to pay for the dermatology services provided on August 5, 2021. The Plan says that the 
documentation does not support a separate evaluation and management service, and the documentation does 
not meet signature requirements. 
 
We decided that the Plan has to pay for procedure codes 17000 and 17003.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Medicare requires that services provided be authenticated by the persons responsible for the care of the 
beneficiary in accordance with Medicare's policies. 
 
We looked at the file and Medicare rules. The documentation submitted does include a valid signature from the 
persons responsible for the care of the beneficiary. The documentation shows that the records were signed on 
August 6, 2021. Based on this information, we decided that Medicare rules for coverage have been met. 
Therefore, we decided that the Plan has to pay for procedure codes 17000 and 17003 billed for date of service 
August 5, 2021.  
 
We also decided that the Plan does not have to pay for procedure code 99213. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code.  
 
We looked at the file and the rules. We find that code 99213 was billed with the -25 modifier. The records 
provided do not show that the evaluation and management service was significantly and separately identifiable 
from minor procedure codes 17000 and 17003. Based on this information, we decided that the Medicare rules 
for coverage have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 
99213 billed for date of service August 5, 2021. 
 
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 genicular artery embolization. 
 
You asked the Plan to pre-approve genicular artery embolization. You say that this is medically necessary. The 
Plan denied your request. The Plan says this is experimental and unproven. 
 
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 genicular artery embolization. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found this is an experimental/investigational procedure. It is the subject of 
ongoing clinical trials. 
 
   
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of genicular artery embolization have not been met. Therefore, we decided that the 
Plan does not have to pre-approve genicular artery embolization.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance transportation services (A0429, A0425) provided 
on June 25, 2023. 
 
You asked the Plan to pay for ambulance transportation. You say that you had fallen and were experiencing 
worsening pain and bruising. It was difficult for you to get into a car without horrible pain and you cannot walk 
without assistance. The Plan denied your request. The Plan says these services were not medically necessary. 
 
Medicare pays for ambulance services only when an emergency exists or when other means of transport would 
endanger the patients health. The Plan follows the same rules.  
 
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 pay for ambulance transportation. Our reviewer says 
that the services at issue were not medically necessary and did not meet criteria for coverage. Our physician 
reviewer found that you had a fall a few days prior and were seen in the emergency department. Your pain 
worsened and 911 was called. When the ambulance arrived, you were sitting up comfortably and were able to 
ambulate with assistance. Your presenting symptoms did not meet prudent layperson criteria for emergency 
care. The documentation does not support that other means of transportation were contraindicated. It does not support that you needed the expertise, services and lifesaving/life-sustaining equipment that only a fully 
equipped ambulance can provide. Finally, it does not support that ambulance transport was medically 
reasonable and necessary in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of ambulance transportation have not been met. Therefore, we decided that the 
Plan does not have to pay for ambulance transportation services (A0429, A0425) provided on June 25, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power operated vehicle (POV) (K0800). 
 
You asked the Plan to pre-approve a POV. You say that you need this POV because your left leg is very 
swollen and full of bruises. The Plan denied your request. The Plan says the requested POV is being denied 
because your home is not accessible to a POV. The Plan also says that there is no evidence that you have a 
secure and accessible place to store a POV. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
 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 POV. Our reviewer says that the 
group 1 power mobility device is not medically necessary. Our physician reviewer found you can ambulate in 
your home with and without the assistance of a cane. You are modified independent with transfers and 
mobility. Our reviewer also found the evaluation indicates that your home is not accessible for a power scooter 
and there is no safe space to store it that is accessible. 
 
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 POV have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a power operated vehicle (POV) (K0800).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Metronidazole. 
 
You asked the Plan to pre-approve the medication. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the medication is not covered as a medical benefit under the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Metronidazole.  Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99204 for date of service October 5, 2023. 
 
You asked the Plan to pay for procedure code 99204. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services billed 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. 
 
In this case, the CPT Code Manual definition of code 99204 is office or other outpatient visit for the evaluation 
and management of a new patient, which requires a medically appropriate history and/or examination and 
moderate level of medical decision making. When using time for code selection, 45-59 minutes of total time is 
spent on the date of the encounter. 
 
 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 code 99204. Our reviewer says that the 
documentation does not support that the code billed is supported. Our reviewer found the records do not 
support a moderate level of medical decision making or highlight than 45 minutes or more of time was 
exceeded. Therefore, code 99204 is not supported. 
 
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 code 99204 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 99204 for date of service October 5, 2023.