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

 
We decided that the Plan does not have to pre-approve bone marrow aspirate (20939).  
 
You asked the Plan to pre-approve bone marrow aspirate. You say that this procedure is medically necessary. 
The Plan denied your request. The Plan says the clinical value and effectiveness of bone marrow aspirate in the 
setting of spinal fusion surgery have not been demonstrated in the peer-reviewed literature.  
 
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 bone marrow aspirate. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that there is no specific indication provided to support the request for bone marrow aspirate for the approved surgery. There is a lack of large volume, long-term peer-reviewed outcome studies to 
support the use of bone marrow aspirate for this enrollees medical condition as discussed above. No 
compelling rationale is presented, or extenuating circumstances noted to support the medical necessity of this 
request as an exception. Therefore, the requested bone marrow aspirate 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 bone marrow aspirate have not been met. Therefore, we decided that the Plan 
does not have to pre-approve bone marrow aspirate (20939).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 power wheelchair with multiple power 
options and accessories (E0955, E0956, E1007, E1012, E1028, E2311, E2313, E2361, E2377, E2607, E2620, 
K0108, K0861). 
 
You asked the Plan to pre-approve a group 3 power wheelchair with multiple power options and accessories. 
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 power mobility devices are 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 a group 3 power wheelchair with multiple power 
options and accessories a group 3 power wheelchair with multiple power options and accessories. Our reviewer 
says that the services are not medically necessary. Our physician reviewer found the enrollee does not have 
high risk for skin breakdown, use a catheter intermittently, have spasticity or require an alternative means of 
managing power drive. 
 
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 group 3 power wheelchair with multiple power options and accessories have 
not been met. Therefore, we decided that the Plan does not have to pre-approve a group 3 power wheelchair 
with multiple power options and accessories (E0955, E0956, E1007, E1012, E1028, E2311, E2313, E2361, 
E2377, E2607, E2620, K0108, K0861).
Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to pay for the services described by procedure code(s) 99152. We decided that the 
Plan does not have to pay for the services described by procedure code(s) 99153.  
 
You asked the Plan to pay for practitioner services provided on March 27, 2023, billed with procedure codes 
99153, 92928-RC, 93459-26-XU, and 99152. You say that the claim is billed correctly and should be paid. The 
Plan says that code 99153 is not payable in the facility setting.  
 
We decided that the Plan has to pay for the services described by procedure code(s) 99152.  
 
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. Specifically, the Plan did not provide a denial rationale for the codes listed in 
this section. The Plan is not allowed to reopen any determinations while an appeal is pending and must issue a 
determination on all appealed services within the appeal time frame. As the Plan forfeited its opportunity to 
provide a denial rationale for these services, we find that the denial of payment is not supported. Therefore, we 
decided that the Plan has to pay for the services described by procedure code(s) 99152.  
 
We also decided that the Plan does not have to pay for the services described by procedure code(s) 
99153. 
 
The Plan follows Medicare rules. Medicare rules say that the OPPS recognizes that CPT code 99153 is a PE 
only code and that PE are not payable to the physician for services provided in the facility setting.  
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the services described by procedure code(s) 99153 have not been met. Specifically, there is no 
separate payment to the physician for CPT code 99153 when performed in the facility setting. Therefore, we 
decided that the Plan does not have to pay for the services described by procedure code(s) 99153. 
 
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 procedure code 87641 provided on November 14, 2022. 
 
You asked the Plan to pay for procedure code 87641. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says 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 87641 is Infectious agent detection by nucleic acid (DNA 
or RNA); Staphylococcus aureus, methicillin resistant, amplified probe technique. 
 
We find that CPT code 87641 is not supported in the medical record. Specifically, the records do not support 
that Staphylococcus aureus, methicillin resistant was tested.  Based on this information, we decided that 
Medicare rules for coverage of procedure code 87641 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 87641 provided on November 14, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator for 9 months (E0466). 
 
You asked the Plan to pre-approve a ventilator for 9 months. 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 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. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not reasonable and 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 a ventilator for 9 months. Our reviewer 
says that the services are not medically necessary. Our physician reviewer found Provided records document 
that the home ventilator is being requested for use in average volume assured pressure support (AVAPS) mode 
which is a modality that could be provided by a bilevel positive airway pressure (BiPAP) device with AVAPS 
and a back-up rate. Provided records do not document trial and failure of a BiPAP device with AVAPS and a 
back-up rate. 
 
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 ventilator for 9 months have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a ventilator for 9 months (E0466).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable controller (E2377) with harness (E2313) 
and electronic connection (E2311) for a power wheelchair. 
 
You asked the Plan to pre-approve an expandable controller with harness and electronic connection. You say 
that the requested items are a medical necessity for you. 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.  
 
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 expandable controller with harness 
and electronic connection. Our reviewer says that the requested items are not considered medically reasonable 
and necessary in this case. Our physician reviewer found that you do have use of the upper extremity and can 
operate and control the power options using the switches that are included in the basic wheelchair. 
 
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 expandable controller with harness and electronic connection have not been 
met. Therefore, we decided that the Plan does not have to pre-approve an expandable controller (E2377) with 
harness (E2313) and electronic connection (E2311) for a power wheelchair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable controller with harness upgrade and 
electronic connection for a power wheelchair (PWC). 
 
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. 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the records do not support that you require non-proportional input devices. You do not require a separate display, other electronic devices, or an 
attendant control for the approved PWC. It is not medically necessary for you to control the requested power 
options through the joystick (drive interface). Your upper extremity strength and functional ability is 
documented as sufficient to control any power options through their own switches. The requested expandable 
controller with harness upgrade and electronic connection are not medically necessary based on the submitted 
records. 
 
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 an expandable controller with harness upgrade and electronic connection for a power 
wheelchair (PWC).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone marrow aspirate. 
 
You asked the Plan to pre-approve bone marrow aspirate. You say that the enrollee has attempted physical 
therapy and the blood test has been completed. 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 bone marrow aspirate. Our reviewer 
says that the requested bone marrow aspirate is not considered medically reasonable and necessary in this case. 
Our physician reviewer found there is a lack of large volume, long-term peer-reviewed outcome studies to support the use of bone marrow aspirate for this enrollees medical condition as discussed above. The reviewer 
found that is no compelling rationale is presented or extenuating circumstances noted to support the medical 
necessity of this request as an exception. Therefore, the reviewer found that the requested bone marrow aspirate 
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 bone marrow aspirate. have not been met. Therefore, we decided that the Plan 
does not have to pre-approve bone marrow aspirate.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 77002 billed for date of service February 7, 
2023. 
 
You asked the Plan to pay for procedure code 77002. You say that the services at issue should be paid. The 
Plan denied your request. The Plan says payment for code 77002 is bundled into payment for code 62321. 
 
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 77002 
is a column II code to column I code 62321. 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 77002 billed for date of service February 7, 
2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided from February 
27, 2023, to March 2, 2023. 
 
You asked the Plan to pay for SNF care. You say that this should be covered by Medicare. The Plan denied 
your request. The Plan says the enrollee no longer required daily skilled 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 pay for 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 did not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs 
that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did 
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 pay for skilled nursing facility (SNF) care provided from February 27, 2023, to March 2, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (85060, 88341 and 88342) provided 
on September 6, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that this testing provides valuable information 
for physicians to use in determining the appropriate treatment. The Plan denied your request. The Plan says the 
primary procedure code 88342 was denied, therefore 88341 is also denied.  
 
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 the laboratory services. Our reviewer found the 
documentation submitted was reviewed and does not meet criteria. The procedure report describes bone 
marrow biopsy. The Health Plan denied payment for code 88342 for included in another procedure reported 
(Current Procedural Terminology (CPT) 88189). This denied correctly for same or similar specimen. In this 
case, since CPT 88341 is an add on code for CPT 88342 - this procedure would not be covered.  
 
Furthermore, code 85060 has a Professional Component (PC)/Technical Component (TC) indicator of 8 per the 
2022 National Physician Fee Schedule Relative Value File July Release. As per Medicare guidance, 85060 is 
not payable with the billed Place of Service (POS) 11 for office. 
 
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 laboratory services have not been met. Therefore, we decided that the Plan 
does not have to pay for the laboratory services (85060, 88341 and 88342) provided on September 6, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ultrasound guided radiation therapy (G6001). 
 
You asked the Plan to pre-approve ultrasound guided radiation therapy. You say that the requested treatment is 
medically necessary. The Plan denied your request. The Plan says there is not enough evidence that this type of 
radiation therapy guidance is needed or effective for the enrollee's skin cancer. 
 
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 ultrasound guided radiation therapy. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found certainly, using ultrasound on a daily basis is not unreasonable to offer 
but not necessary. The device itself is Food and Drug Administration (FDA) approved for use with ultrasound 
though that in and of itself does not mean that daily imaging is necessary but simply that the device was designed to incorporate this functionality. Therefore, to bill for daily simple simulations and/or image-guided 
radiotherapy (IGRT) for a technology for which need has not been established by published data or supported 
by consensus guidelines (many of which recommend against treatment with these devices in general) is not 
necessary. The decision is unfavorable as billing for daily IGRT which would not be furnished in accordance 
with accepted standards of medical practice. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of ultrasound guided radiation therapy have not been met. Therefore, we decided 
that the Plan does not have to pre-approve ultrasound guided radiation therapy (G6001).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you need the physical and occupational therapy to 
aid in regaining function, mobility and strength. You also say that you want to walk again and are willing to 
participate in your care for recuperation and rehabilitation. The Plan denied your request. The Plan says based 
on the available information, admission to the IRF is not reasonable and necessary as your condition does not 
meet Medicare rules. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of your nursing, medical and rehabilitation needs do not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You have a history of 
weakness and urinary tract infection and are living at home with ongoing weakness. Medical problems are 
stable. There are no complex nursing or rehabilitation needs. While the medical records support a need for 
physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. 
Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that 
you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in 
an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.