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

 
We decided that the Plan does not have to pay for procedure code G0481 billed for date of service August 18, 
2022. 
 
You asked the Plan to pay for the billed services. You say that medical records were provided. The Plan denied 
your request. The Plan says the drug classes tested do not match the billed code. 
 
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 G0481 is definitive drug testing of 8-14 drug classes. We 
find that CPT code G0481 is not supported in the medical record. The records show that more than 14 drug 
classes were tested. There is a more accurate code that describes the services provided. Based on this 
information, we decided that Medicare rules for coverage have not been met. Based on this information, we 
decided that Medicare rules for coverage of the billed services have not been met. Therefore, we decided that 
the Plan does not have to pay for procedure code G0481 billed for date of service August 18, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve skin substitutes.  
 
You asked the Plan to pre-approve skin substitutes. You say that it is medically necessary. The Plan denied 
your request. The Plan says that it is not medically necessary. 
 
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 skin substitutes. Our reviewer says that 
the requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found it is medically necessary to avoid a surgical procedure and potential serious complications. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of skin substitutes have been met. Therefore, we decided that the Plan has to pre-
approve skin substitutes.   
 
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 a left atrial appendage closure (LAAC) device (93650, 
33228, 33340). 
 You asked the Plan to pre-approve the LAAC device. You say that the enrollee has a history of frequent falls. 
You say that this puts the enrollee at significant risk for major bleeding. You also say that due to religious 
beliefs, the enrollee will not accept blood transfusions. The Plan denied your request. The Plan says the record 
does not support that the enrollee is unable to take long term anticoagulation. 
 
The Plan follows Medicare rules. Medicare rules say that LAAC devices are covered when the device has 
received Food and Drug Administration (FDA) Premarket Approval (PMA) for that devices FDA-approved 
indication and meet all of the conditions including a contraindication to anticoagulation. 
 
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 LAAC device. Our reviewer says 
that the requested LAAC device is not medically necessary. Our physician reviewer found the provided 
documentation does not indicate an apparent contraindication to anticoagulation and the enrollee has had no 
history of bleeding. The documentation indicates the enrollee is felt to be at increased risk from bleeding if they 
were to fall. Due to the enrollee's beliefs, they cannot be transfused.  As such, guidelines would not support 
implantation of a LAAC in this setting. In summary, LAAC placement would not be considered reasonable or 
medically necessary in the enrollees clinical management. 
 
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 LAAC device have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a left atrial appendage closure (LAAC) device (93650, 33228, 33340).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87481, 87653, 87798, and 87801 billed for 
date of service February 27, 2023. 
 You asked the Plan to pay for procedure code 87481. You say that you disagree with the denial. The Plan 
denied your request. The Plan says payment for codes 87481, 87653, 87798, and 87801 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 codes 
87481, 87653, 87798, and 87801 are column II codes to column I code 87801. This claim has not been billed 
with an appropriate modifier to bypass the edit. The -XU modifier is not supported as a separate and distinct 
procedural service. 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 codes 87481, 87653, 87798, and 87801 billed for date 
of service February 27, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 64702 billed for date of service March 15, 
2023. 
 You asked the Plan to pay for procedure code 64702. The Plan denied your request. The Plan says payment for 
code 64702 is bundled into payment for code 26116. 
 
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 64702 
is a column II code to column I code 26116. 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 64702 billed for date of 
service March 15, 2023.
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 required care cannot be managed at a 
lower level of care and risks further deterioration if not approved for LTACH. The Plan denied your request. 
The Plan says the enrollee does not meet the Medicare criteria for LTACH services. 
 
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 medical record does not indicate that the enrollee requires services that they are 
not currently receiving. The enrollee still requires acute care services before transitioning to a lower 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 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 superion interspinous spacer/Vertiflex device. 
 
You asked the Plan to pre-approve Vertiflex device. You say that this service is not considered to be the 
accepted standard of medical practice as there is unclear guidance and minimal support for the use of this 
technology. The Plan denied your request. The Plan says enrollee reported lower back pain that was 9/10 in 
intensity. 
 
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 Vertiflex device. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the Vertilfex device is experimental, and more research is needed. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Vertiflex device have not been met. Therefore, we decided that the Plan does 
not have to pre-approve superion interspinous spacer/Vertiflex device.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for etelcalcetide injections (J0606) provided from December 2, 
2022, to December 30, 2022. 
 
You asked the Plan to pay for etelcalcetide injections. You say that you have billed the services at issue 
correctly. The Plan denied your request. The Plan says rules for payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare contractors should discontinue 
processing the TDAPA for J0604 and J0606 when billed with modifier AX on Type of Bill 72X for from dates 
on or after January 1, 2021. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of etelcalcetide injections have not been met. The case record supports that code J0606 was billed inappropriately with modifier AX. Therefore, we decided that the Plan does not have to pay for etelcalcetide 
injections (J0606) provided from December 2, 2022, to December 30, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a seat lift mechanism (E0627) and accessories (E1399). 
 
You asked the Plan to pre-approve a seat lift mechanism and accessories. You say that the items are medically 
necessary. The Plan denied your request. The Plan says the items are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions 
listed in the Medicare rules section 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 a seat lift mechanism and accessories. 
Our reviewer says that the items are not medically necessary. Our physician reviewer found there is no clinical information provided indicating that the patient cannot independently perform transfers in her home. 
 
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 seat lift mechanism and accessories have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a seat lift mechanism (E0627) and accessories (E1399).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the skilled nursing services and physical therapy visits. 
 You asked the Plan to pre-approve home health services. You say that you need the services for home health 
care. 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 that the record 
indicates the enrollee has an unstable gait. There are no skilled nursing needs evident. There is no evidence the 
enrollee is home bound; therefore, the enrollee does not have skilled nursing needs. 
 
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 the skilled nursing services and physical therapy visits.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve an Ottobock C-leg (L5828, L5845, L5848, L5850, L5856), Ossur 
Pro-flex foot ((L5981, L5986), and alignable system (L5920). 
 
You asked the Plan to pre-approve an Ottobock C-leg, Ossur Pro-flex foot, and alignable system. You say that 
the items are medically necessary. The Plan denied your request. The Plan says that the items are not medically 
necessary. 
 
The Plan follows Medicare rules. Medicare rules say that coverage is extended only if there is sufficient 
clinical documentation of functional need for the technologic or design feature of a given type of knee. This 
information must be retained in the treating practitioner's or prosthetist's files. 
 
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 an Ottobock C-leg, Ossur Pro-flex foot, 
and alignable system. Our reviewer says that the enrollee meets the criteria for these items. Our physician 
reviewer found the items 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 an Ottobock C-leg, Ossur Pro-flex foot, and alignable system have been met. 
Therefore, we decided that the Plan has to pre-approve an Ottobock C-leg (L5828, L5845, L5848, L5850, 
L5856), Ossur Pro-flex foot ((L5981, L5986), and alignable system (L5920).  
 
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 a T12 kyphoplasty procedure. 
 
You asked the Plan to pre-approve a kyphoplasty procedure. You say that the enrollee has been complaining 
about back pain. The Plan denied your request. The Plan says the enrollee's vertebral compression fracture is 
not acute/subacute (less than 12 weeks in age). 
 
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 kyphoplasty procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee's compression fracture at T12 has been noted on imaging studies since 
January 24, 2023, indicating this is not an acute or subacute fracture. Additionally, 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. 
 
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 kyphoplasty procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a T12 kyphoplasty procedure.
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. The Plan denied your request. The Plan says the enrollee's 
records do not show the need for skilled services daily. 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for portable X-ray services provided on January 12, 2023. 
 
You asked the Plan to pay for portable X-ray services. You say that you have billed the services at issue 
correctly. The Plan denied your request. The Plan says the services at issue were billed with an incorrect POS 
code. 
 
The Plan must follow Medicare rules. Medicare rules say that when services are furnished in a mobile unit, 
they are often provided to serve an entity for which another POS code exists. If the mobile unit is serving an 
entity for which another POS code already exists, providers should use the POS code for that entity. 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of portable X-ray services have not been met. Specifically, the services at issue have been reported 
with POS code 11, indicating an office setting. The case record does not support that POS code 11 is warranted 
in this case. Therefore, we decided that the Plan does not have to pay for portable X-ray services provided on 
January 12, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on March 31, 2023, billed with 
codes 81432 and 81433. 
 
You asked the Plan to pay for the genetic testing billed. You say that the results of the test directly impact 
clinical decision making. The Plan denied your request. The Plan says panel testing should be billed using one 
CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. We looked at the file and Medicare rules. This NGS panel that was not billed with a single panel code as 
required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
March 31, 2023, billed with codes 81432 and 81433.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 00811 billed for date of service February 26, 
2023. 
 
You asked the Plan to pay for the billed services. You say that the place of service is correct. The Plan denied 
your request. The Plan says an incorrect place of service was billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
 The claim at issue was billed with an outpatient place of service code. The claim information shows that the 
enrollee was receiving inpatient care at the time the services at issue were provided. Based on this information, 
we decided that Medicare rules for coverage of the billed services have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure code 00811 billed for date of service February 26, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has severe chronic obstructive pulmonary disease (COPD) and requires home oxygen, but there is no documented data to support 
a home ventilator. There is no arterial blood gas (ABG) or laboratory data to suggest hypercapnia. The criteria 
for coverage are not met and the home ventilator is not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a home ventilator.