Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services (99223) provided on March 2, 2023. 
 
You asked the Plan to pay for the physician services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the documentation does 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 99223 is initial hospital 
inpatient or observation care, per day for the evaluation and management of a patient that requires a medically 
appropriate 
history and/or examination and high level of medical decision making, or must meet or exceed 75 minutes of 
total time 
(non-face to face to face total time) 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 the physician services. Our reviewer says that the billed code 
is not supported by the records. Our reviewer found the records support an appropriate exam, but not an 
appropriate history or medical decision making of high complexity. 
 
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 physician services have not been met. Therefore, we decided that the Plan 
does not have to pay for physician services (99223) provided on March 2, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87798-91 (x13), 87652, 87899 and 87900 
billed for date of service June 1, 2022. 
 
You asked the Plan to pay for procedure codes 87798-91 (x13), 87652, 87899 and 87900. You say that these 
services were necessary and should be paid. The Plan denied your request. The Plan says these codes are not 
supported in the medical record. 
 
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 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 87798-91 (x13), 87652, 87899 and 87900. 
Our reviewer says that these codes are not supported in the medical record. Our reviewer found the 
documentation does not support modifier 91 (repeat clinical diagnostic laboratory test) for 13 units for code 87798. The attached records do not document that repeat testing was performed. In addition, the records do not 
support codes 87652, 87899 and 87900 as there is no documentation of strep A testing, testing for drug 
resistance, or infectious agent antigen detection by immunoassay with direct optical (i.e., visual) observation. 
 
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 87798-91 (x13), 87652, 87899 and 87900 have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure codes 87798-91 (x13), 87652, 87899 
and 87900 billed for date of service June 1, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a MyoPro Motion G orthosis (L8702). 
 
You asked the Plan to pre-approve a MyoPro orthosis. You say that a MyoPro orthosis is a medical necessity 
for the enrollee. The Plan denied your request. The Plan says a MyoPro orthosis is 
experimental/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 MyoPro orthosis. Our reviewer says 
that the requested item is not considered medically reasonable and necessary in this case. Our physician 
reviewer found that the MyoPro orthosis is not known to be effective, based on scientific evidence, 
professional standards and expert opinion, in improving health outcomes. The MyoPro orthosis is not the 
standard of care for the enrollee's condition or in widespread use for the enrollee's condition based on scientific evidence. There is insufficient evidence in the literature that the MyoPro orthosis will improve the long-term 
outcomes for the enrollee or that this device will increase participation in bimanual activities. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a MyoPro orthosis have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a MyoPro Motion G orthosis (L8702).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve stereotactic radiosurgery (SRS) (77372, 77373). 
 
You asked the Plan to pre-approve SRS. You say that the enrollee was diagnosed with a small cell lung cancer 
arising from the left hilum with ipsilateral pleural disease and malignant pleural effusion In March 2023. You 
recommend SRS for this enrollee's limited volume intracranial metastatic disease. The Plan denied your 
request. The Plan says that there is no good evidence the requested treatment is the best or a good treatment for 
the enrollee's condition. 
 
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 SRS. Our reviewer says that the 
requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found SRS is an accepted standard of care for limited metastases from small cell lung cancer. The 
American Society for Radiation Oncology (ASTRO) model policy for radiosurgery lists no restrictions on SRS 
based upon primary cancer type or number of lesions, or prior treatment (i.e., having undergone prior SRS) but 
rather emphasizes the need of SRS in enrollees with good performance status, and who are expected to have a 
reasonably long-life expectancy warranting treatment. The National Comprehensive Cancer Network (NCCN) 
guidelines for brain metastases explicitly state: The NCCN Panel decided that SRS may be used for selected 
enrollees with a small number of brain metastases based on available data, pending outcomes of the ongoing 
trials. as well as Brain metastases have conventionally been treated with whole brain radiation therapy 
(WBRT); however, selected enrollees with a small number of metastases may be appropriately treated with 
stereotactic radiotherapy (SRT)/radiosurgery (SRS). Given that the treatment of 5+ small brain metastases 
with SRS in an enrollee with small cell lung cancer with good performance status is in accordance with 
accepted standard practice, the reviewer believes that the treatment can be considered within accordance of 
accepted standards of medical practice and therefore is 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 SRS have been met. Therefore, we decided that the Plan has to pre-approve 
stereotactic radiosurgery (SRS) (77372, 77373).  
 
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 insertion of the Vertiflex Superion device. 
 
You asked the Plan to pre-approve the Vertiflex device. You say that the enrollee has failed more than 12 
months of conservative approaches to treatment at this time. You also say that this is medically necessary for 
the enrollee. The Plan denied your request. The Plan says there is a lack of evidence (only a retrospective 
series) on the efficacy of interspinous fixation devices as a stand-alone procedure for those who have spinal 
stenosis and/or spondylolisthesis. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the Vertiflex device. Our reviewer says 
that the requested Vertiflex device is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the Vertiflex device is considered experimental as additional research is needed. Therefore, the reviewer found that the Vertiflex device 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 Vertiflex device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve insertion of the Vertiflex Superion device.
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 requires high level of care to 
attain baseline status, along with avoidance of depakote and apixaban given concurrently, as depakote reduces 
the efficacy of apixaban, and is currently on IV antibiotics and anticoagulant regime. The Plan denied your 
request. The Plan says at the time of the request, the enrollee's status is critical and is currently receiving 
medically necessary acute and/or critical care. 
 
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 there are no services available at the LTACH that the enrollee requires that are not available at the current health care setting being offered by the health plan. 
 
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: 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 not safe to go home, lives alone, is a 
fall risk, has anxiety and depression, is very ambulatory unsteady, weak, and has no one to help.  The Plan 
denied your request. The Plan says the enrollee does not meet Medicare guidelines because no longer requires 
skilled services on a daily inpatient basis and the continuation of skilled nursing services. 
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87150, 87481, 87500, 87640, 87641, 87651, 
87653, 87798, and 87801, billed for date of service January 16, 2023. 
 
You asked the Plan to pay for procedure codes 87150, 87481, 87500, 87640, 87641, 87651, 87653, 87798, and 
87801. 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. In this case, we have confirmed that code 87150 
is a column II code to column I code 87500. We have also confirmed that codes 87481, 87640, 87641, 87651, 
87653, and 87798, are column II codes 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. 
 
We find that CPT code 87801 is not supported in the medical record. Specifically, the records provided do not 
confirm the multiple organisms represented by code 87801. Based on this information, we decided that 
Medicare rules for coverage of procedure code 87801 have not been met. 
 
We also find that for code 87500, the documentation submitted does not contain a valid physician order or lab 
requisition for the billed testing. The documentation submitted does not contain medical records showing the 
ordering physicians intent that this specific testing be performed. Therefore, we decided that the Plan does not 
have to pay for procedure codes 87150, 87481, 87500, 87640, 87641, 87651, 87653, 87798, and 87801, billed 
for date of service January 16, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health skilled nursing and home health aide 
services. 
 You asked the Plan to pre-approve home health services. You say that it is felt that home health services are 
needed.  The Plan denied your request. The Plan says the services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found the clinical 
documentation supports an ongoing need for assessment of lower limb edema; however, it does not confirm 
that the enrollee is home bound (he is documented ambulating independently and leaving home). Thus, the 
records do not show that skilled nursing services are required in the home setting to effectively provide 
treatment, care, and/or services in order to improve the enrollee's condition, or to establish/perform a 
maintenance program to maintain the enrollee's condition and/or prevent deterioration. Clinical documentation 
does not support a care plan in which the skilled services of a professional home health aide would be 
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 home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home health skilled nursing and home health aide services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87481, 87491, 87563, 87640, 87653, 87798, 
87641, and 87500 billed for March 28, 2023. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure codes 87481, 87491, 87563, 87640, 87653, 87798, 87641, and 87500 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 87481 is infectious agent detection by nucleic acid (DNA 
or RNA); Candida species, amplified probe technique. The definition of code 87491 is infectious agent 
detection by nucleic acid (DNA or RNA); Chlamydia trachomatis, amplified probe technique. The definition of 
code 87563 is infectious agent detection by nucleic acid (DNA or RNA); Mycoplasma genitalium, amplified probe technique. The definition of code 87640 is infectious agent detection by nucleic acid (DNA or RNA); 
Staphylococcus aureus, amplified probe technique. The definition of code 87653 is infectious agent detection 
by nucleic acid (DNA or RNA); Streptococcus, group B, amplified probe technique. The definition of code 
87798 is infectious agent detection by nucleic acid (DNA or RNA); Streptococcus, group B, amplified probe 
technique. The definition of code 87798 is infectious agent detection by nucleic acid (DNA or RNA), not 
otherwise specified; amplified probe technique, each organism. The definition of code 87641 is infectious 
agent detection by nucleic acid (DNA or RNA); Staphylococcus aureus, methicillin resistant, amplified probe 
technique. The definition of code 87500 is infectious agent detection by nucleic acid (DNA or RNA); 
vancomycin resistance (eg, enterococcus species van A, van B), amplified probe technique. 
 
We find that CPT codes 87481, 87491, 87563, 87640, 87653, 87798, 87641, and 87500 are not supported in the 
medical record. Specifically, the records show that a panel of testing was performed and there is a more 
appropriate single code for the services. Based on this information, we decided that Medicare rules for 
coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure codes 87481, 87491, 87563, 87640, 87653, 87798, 87641, and 87500 billed for March 28, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from October 19, 2022, to 
November 17, 2022. 
 You asked the Plan to pay for the home health services. You say that you have submitted two NOAs, but the 
first one had a billing error. You said that the first NOA was submitted on August 28, 2022, but it was rejected.  
The Plan denied your request. The Plan says the NOA was not received timely. As such, this final claim was 
correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is February 21, 2022. The NOA was not received by the Plan until February 
6, 2023. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for home health services provided 
from October 19, 2022, to November 17, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the GeneSight Psychotropic test (0345U) provided on March 
14, 2023. 
 
You asked the Plan to pay for the GeneSight Psychotropic test. You say that this test is medically necessary to 
inform clinicians about which medication may require dose adjustment, may be less likely to work, or may 
have an increased risk of side effects based on a patients genetic makeup. The Plan denied your request. The 
Plan says GeneSight Psychotropic has not been shown to be useful, is not considered medically necessary and 
appropriate. 
 
The Plan follows Medicare rules. Medicare rules say that this testing is covered when the criteria in the rules 
section of this letter 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 pay for the GeneSight Psychotropic test. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found GeneSight 
Psychotropic has not been shown to be useful, is not considered medically necessary and appropriate. The 
review has determined that in this case, the enrollee does not meet the criteria for coverage for this testing. 
 
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 GeneSight Psychotropic test have not been met. Therefore, we decided that 
the Plan does not have to pay for the GeneSight Psychotropic test (0345U) provided on March 14, 2023.