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

 
We decided that the Plan has to pay for procedure code 87505 rendered on September 5, 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 that a panel cannot be unbundled and billed as individual components regardless of the fact that 
the test reports multiple individual pathogens and/or targets. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The plan has submitted an invalid denial reason, as there is only one code still 
denied in this case, and the denial reason is about unbundling multiple codes for laboratory services. Therefore, 
we decided that the Plan has to pay for procedure code 87505 rendered on September 5, 2022.  
 
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 facet joint injection services at a third level.  
 
You asked the Plan to pre-approve facet joint injection services at a third level. You say that the records 
provided support the need for the services which remain in dispute.  The Plan denied your request. The Plan 
says coverage rules limit facet joint injection services to 1 to 2 levels.  
 
The Plan follows Medicare rules. Medicare rules say that the need for a 3 or 4-level medial branch block 
procedure bilaterally may be considered under unique circumstances and with sufficient documentation of 
medical necessity on appeal. 
 
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 facet joint injection services at a third 
level. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the 
enrollee has chronic axial low back pain despite home exercises and medications. His magnetic resonance 
imaging (MRI) shows facet degeneration. He was unable to tolerate physical therapy due to pain. The LCD limits utilization of Medial Branch Blocks to 2 levels per session unless there are extraordinary circumstances.  
No such documentation is presented and therefore, the request for a third level is deemed not medically 
reasonable and 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 facet joint injection services at a third level have not been met. Therefore, we 
decided that the Plan does not have to pre-approve facet joint injection services at a third level.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a harness (E2313), an expandable controller (E2377), 
and other accessories (K0108). 
 
You asked the Plan to pre-approve the upgraded electronics and other accessories. You say that you are 
requesting reconsideration of the denied authorization. The Plan denied your request. The Plan says the 
requested items are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules also say that for equipment to be covered, it must primarily serve a 
medical purpose. 
 
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 upgraded electronics. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee had adequate upper body strength to manage the standard power 
drive controls. 
 
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 upgraded electronics have not been met. The requested cup holder, reduce 
drive, and tray table do not serve a medical purpose. The requested arm pads are unbundled and cannot be 
requested separately. The requested mechanical switch is included in code E2377 and cannot be requested 
separately. Therefore, we decided that the Plan does not have to pre-approve a harness (E2313), an expandable 
controller (E2377), and other accessories (K0108).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connection device (E2311), a harness 
(E2313), an expandable controller (E2377), a narrow corpus footplate (K0108), and a seat liner (K0108). 
 
You asked the Plan to pre-approve the upgraded electronics, footplate, and seat liner. You say that you are 
requesting reconsideration of the denied authorization. The Plan denied your request. The Plan says the 
upgraded electronics are 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 upgraded electronics. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee has adequate upper body strength to manage the standard power 
drive controls. 
 
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 upgraded electronics have not been met. The requested footplate is 
unbundled and cannot be approved as a footplate has a specific HCPCS code. Code K0108 cannot be used for 
components of the wheelchair seat cushion. Therefore, we decided that the Plan does not have to pre-approve 
an electronic connection device (E2311), a harness (E2313), an expandable controller (E2377), a narrow corpus 
footplate (K0108), and a seat liner (K0108).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the enrollee is ready for the next level of care and 
the family is not able to provide the care needed at home and lacks the mental capacity to be independent. The 
Plan denied your request. The Plan says the enrollee's records do not show the need for daily skilled services 
that can be provided only on an inpatient basis in a SNF. Services needed may be provided safely in a lower 
level of care. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing 
facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connection device (E2311), a harness 
(E2313) and an expandable controller (E2377).  
 
You asked the Plan to pre-approve the upgraded electronics. You say that you disagree with the denial and 
request reconsideration. The Plan denied your request. The Plan says the enrollee's upper limb strength and 
function are adequate to be able to control the power options using their own switches. 
 
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 upgraded electronics. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee has adequate upper body strength to manage the standard power 
drive controls. 
 
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 upgraded electronics have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an electronic connection device (E2311), a harness (E2313) and an expandable 
controller (E2377).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Trastuzumab-anns (Kanjinti) 10MG injection (Q5117). 
 
You asked the Plan to pre-approve the drug. You say that the drug is medically necessary. The Plan denied 
your request. The Plan says the drug is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 drug. Our physician reviewer found 
the requested use of Trastuzumab-anns (Kanjinti) 10MG injection (Q5117) is not Food and Drug Administration (FDA)-approved for the enrollees diagnosis. The use is not supported by one of the major drug 
compendia or by clinical research that appears in a Centers for Medicare & Medicaid Services (CMS)-
approved medical journal. It has shown that unlike breast cancer, Trastuzumab is not associated with good 
objective response in HER2 mutated patients in ovarian cancer.  
 
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 drug have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Trastuzumab-anns (Kanjinti) 10MG injection (Q5117).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the L4 kyphoplasty (22514). 
 
You asked the Plan to pre-approve the service. You say that the service is medically necessary. The Plan 
denied your request. The Plan says the service is not 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 the service. Our physician reviewer 
found the detailed documentation is not evident regarding worsening pain. The enrollee has presented to the 
emergency department three (3) times; however, was not hospitalized. There is no indication of a progression 
of the body height loss, kyphotic deformity, or a severe impact on his daily activities. Moreover, there is 
magnetic resonance imaging (MRI) corroboration of retropulsion and other plausible causes of low back 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 the service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the L4 kyphoplasty (22514).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve manipulation of the wrist under anesthesia (25259).  
 
You asked the Plan to pre-approve manipulation of the wrist under anesthesia. 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 manipulation of the wrist under 
anesthesia. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found a literature search did not reveal sufficient high-quality evidence supporting long-term efficacy and safety over other standard treatment options for the enrollee's 
condition. Therefore, without sufficient support made, the request for manipulation with anesthesia will be 
considered not medically necessary at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of manipulation of the wrist under anesthesia have not been met. Therefore, we 
decided that the Plan does not have to pre-approve manipulation of the wrist under anesthesia (25259).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Mohs micrographic surgery. 
 
You asked the Plan to pre-approve Mohs micrographic surgery. You say that the member has a 2 cm ill-defined 
border multifocal superficial Basal Cell Carcinoma (BCC) on right suprascapular area and per CMS 
Guidelines, the authorization should be approved. The Plan denied your request. The Plan says that the member 
does not meet CMS LCD L33689, Mohs Surgery Guidelines: The use of Mohs in these areas and for these 
conditions is not considered medically reasonable and necessary: Basal cell carcinoma located in Area Left - 
trunk and extremities: Primary superficial Basal Cell Carcinoma (BCC) of any size. 
 
The Plan follows Medicare rules. Medicare rules say that Mohs micrographic surgery 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 Mohs micrographic surgery. Our 
reviewer says that the requested Mohs micrographic surgery is not considered medically necessary. Our 
physician reviewer found that Mohs micrographic surgery is not a standard of care for such tumors.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Mohs micrographic surgery have not been met. Therefore, we decided that the 
Plan does not have to pre-approve Mohs micrographic surgery.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve L1 and L3 kyphoplasty (22514, 22515). 
 
You asked the Plan to pre-approve L1 and L3 kyphoplasty. You say that this is medically necessary. The Plan 
denied your request. The Plan says the enrollee does not meet criteria. The documentation notes spinal and 
bilateral foraminal stenosis. 
 
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 L1 and L3 kyphoplasty. Our reviewer 
says that the enrollee does not meet coverage criteria. Our physician reviewer found detailed documentation is 
not evident regarding a progression of the body height loss, greater than 25% vertebral body height loss at both 
L1 and L3, or kyphotic deformity. Moreover, there is MRI corroboration of plausible other causes of the 
lumbar 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 L1 and L3 kyphoplasty have not been met. Therefore, we decided that the Plan 
does not have to pre-approve L1 and L3 kyphoplasty (22514, 22515).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve kyphoplasty (22513). 
 
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 documentation is not evident regarding 
worsening pain. There is no indication of a progression of the body height loss, greater than 25% vertebral 
body height loss, kyphotic deformity, or a severe impact on her daily activities. Moreover, there is magnetic 
resonance imaging (MRI) corroboration of other plausible causes of her back 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 (22513).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve kyphoplasty of the L2 vertebrae with moderate sedation 
(22514, 99152). 
 
You asked the Plan to pre-approve kyphoplasty of the L2 vertebrae. You say that this service is necessary to 
treat the enrollee's symptoms. The Plan denied your request. The Plan says the criteria for coverage of these 
services are not met as the enrollee has multifactorial pain with multilevel disc disease in the lower thoracic 
spine. 
 
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 kyphoplasty of the L2 vertebrae. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the enrollee presented non-hospitalized with moderate to severe pain rated 
at 7/10. However, detailed documentation is not evident regarding worsening pain. There is no indication of a 
progression of the body height loss, kyphotic deformity, or a severe impact on daily activities. Moreover, there 
is computed tomography (CT) corroboration of plausible other causes of low back pain. Therefore, the 
requested kyphoplasty at L2 vertebrae 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 kyphoplasty of the L2 vertebrae have not been met. Therefore, we decided that 
the Plan does not have to pre-approve kyphoplasty of the L2 vertebrae with moderate sedation (22514, 99152).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87481 billed for date of service December 
10, 2022. 
 
You asked the Plan to pay for procedure code 87481. You say that the claim should be paid. The Plan denied 
your request. The Plan says payment for code 87481 is bundled into payment for code 87801. 
 
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 87481 
is a column II code to column I code 87801. 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 87481 billed for date of service December 10, 
2022.
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 the computed tomography (CT) scan 
indicated that there has been increase in pathology since January 17, 2023. This supports the vertebral fracture 
is not acute or subacute. Additionally, you are non-hospitalized with moderate to severe pain that he rates at 
7/10. However, detailed documentation is not evident regarding worsening pain. Moreover, there is CT and x-
ray corroboration of retropulsion. Therefore, you do 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).