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

 
We decided that the Plan does not have to pre-approve a kyphoplasty (22513 and 22515). 
 
You asked the Plan to pre-approve the services. You say that the enrollee does not meet the criteria for 
coverage.  The Plan denied your request. The Plan says the enrollee has tried physical therapy, epidural steroid 
injections and bracing with no relief or worsened pain. You say that the enrollee would benefit from the 
kyphoplasty procedure, and the denial should be reconsidered.  
 
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 services. Our physician reviewer 
found the detailed documentation is not evident regarding clear osteoporotic fractures at the requested levels. 
There is no indication of a diagnosis of osteoporosis or treatment for such. Moreover, there is magnetic 
resonance imaging (MRI) corroboration of other plausible causes of pain. Therefore, the enrollee does not meet 
the LCD criteria for coverage. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a kyphoplasty (22513 and 22515).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87186 billed for date of service January 23, 
2023. 
 
You asked the Plan to pay for procedure code 87186. You say that this service was necessary and is supported 
in the medical record. The Plan denied your request. The Plan says this code is 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. 
 
In this case, the CPT Code Manual definition of code 87186 is susceptibility studies, antimicrobial agent; 
microdilution or agar dilution (minimum inhibitory concentration [MIC] or breakpoint, each multi-
antimicrobial, per plate. 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for procedure code 87186. Our reviewer says that this code is 
not supported in the records provided. Our reviewer found the medical records included a physician order from 
one facility with a laboratory report from a hospital. In this case, the first facility billing for services provided 
by the hospital cannot be verified. This claim was appropriately denied, as documentation does not support 
service billed. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 87186 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 87186 billed for date of service January 23, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power wheelchair (K0861) and accessories (E0955, E1007, E1012, E1028, E2300, E2311, E2313, E2361, E2377, E2620, E2622, K0040).

You asked the Plan to pre-approve a power wheelchair and accessories. You say that you are unable to walk and attend medical appointments. You need a power wheelchair to recline. The Plan denied your request. The Plan says a special power wheelchair is medically necessary when you require both power tilt and power recline. The notes do not show that you need both of these power options. 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 a power wheelchair and accessories. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found you have a neurologic disorder with functional deficits. The documentation does not indicate that you have any pressure injuries or require intermittent catheterization of the bladder or have spasticity that would necessitate power tilt or recline. Although your condition may meet criteria for a PWC, the criteria for this specifically requested PWC with multiple power options including power tilt and recline are not met.

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 power wheelchair and accessories have not been met. Therefore, we decided that the Plan does not have to pre-approve a power wheelchair (K0861) and accessories (E0955, E1007, E1012, E1028, E2300, E2311, E2313, E2361, E2377, E2620, E2622, K0040).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous vertebral augmentation, including cavity 
creation using mechanical device, 1 vertebral body, unilateral or bilateral cannulation, inclusive of all imaging 
guidance; lumbar (22514). 
 
You asked the Plan to pre-approve percutaneous vertebral augmentation. You say that you are requesting 
reconsideration due to medical necessity. The Plan denied your request. The Plan says the enrollee does not 
meet criteria for the requested procedure. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve percutaneous vertebral augmentation. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found there is no imaging study showing that the fracture is less than twelve 
(12) weeks old. 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of percutaneous vertebral augmentation have not been met. Therefore, we decided 
that the Plan does not have to pre-approve percutaneous vertebral augmentation, including cavity creation using 
mechanical device, 1 vertebral body, unilateral or bilateral cannulation, inclusive of all imaging guidance; 
lumbar (22514).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the radiofrequency ablation (RFA) for the sacroiliac joint 
(64625) provided on December 1, 2022, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the RFA. You say that the enrollee presented for an approved procedure. You 
also say that the medical service was in the best interest of the enrollee. The Plan denied your request. The Plan 
says prior authorization was not obtained. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the services at issue in this appeal. The Plan did not pre-approve the service at issue. 
We found no exception that would require the Plan to pay for these services. Therefore, we decided that the 
Plan does not have to pay for the radiofrequency ablation (RFA) for the sacroiliac joint (64625) provided on 
December 1, 2022, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87798 billed for date of service December 
13, 2022.  
 
You asked the Plan to pay for procedure code 87798. You say that these services are supported in the medical 
record. The Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed.  
 
The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 87798 is 13. The MAI value for this code is 3. You billed 19 units of this 
code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were 
actually provided, were correctly coded, and were medically necessary. Based on this information, we decided 
that Medicare rules for coverage of procedure code 87798 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 87798 billed for date of service December 13, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a kyphoplasty (22514). 
 
You asked the Plan to pre-approve the service. You say that the enrollee has intense pain and wears a brace all 
the time. You say that the enrollee has an acute compression fracture and needs a kyphoplasty done quickly 
because the pain is so severe. The Plan denied your request. The Plan says the enrollee does not meet the 
criteria for coverage.  
 
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 detailed documentation is not evident regarding an acute or subacute compression fracture. The enrollee 
is not clearly diagnosed with osteoporosis or being treated for such. There is no indication of a progression of 
the body height loss, greater than 25 percent vertebral body height loss, kyphotic deformity, or a severe impact 
on daily activities. Moreover, there is magnetic resonance imaging (MRI) corroboration of multiple other 
plausible causes of pain. Therefore, the enrollee does not meet the LCD criteria for coverage. 
 
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 a kyphoplasty (22514).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (81225 and 81226) provided on November 18, 
2022. 
 
You asked the Plan to pay for the lab services. You say that you would like the Plan to reconsider their denial 
of payment. The Plan denied your request. The Plan says you billed with an incorrect place of service on the 
claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services (81225 and 81226) provided on November 18, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve S1/3 vertebroplasty (22511). 
 
You asked the Plan to pre-approve S1/3 vertebroplasty. You say that this is medically necessary. The Plan 
denied your request. The Plan says medical necessity coverage criteria is not met due to multifactorial 
etiologies of enrollee's pain. 
 
The Plan follows Medicare rules. Medicare rules say that vertebroplasty 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 S1/3 vertebroplasty. Our reviewer says 
that the enrollee does not meet criteria for coverage. Our physician reviewer found detailed documentation is 
not evident the fracture is not from T1-L5. 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 daily activities. 
Moreover, there is magnetic resonance imaging corroboration of other plausible causes for the back 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 S1/3 vertebroplasty have not been met. Therefore, we decided that the Plan does 
not have to pre-approve S1/3 vertebroplasty (22511).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve DownTube Legrest assembly components. 
 
You asked the Plan to pre-approve the items. You say that the enrollee requires these things for the wheelchair. 
The Plan denied your request. The Plan says these do not serve a primarily medical purpose. 
 
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 items. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the down tube assembly is not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the items have not been met. Therefore, we decided that the Plan does not have 
to pre-approve DownTube Legrest assembly components.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bilateral facet joint injection. 
 
You asked the Plan to pre-approve a bilateral facet joint injection. You say that the requested bilateral facet 
joint injection is medically necessary. The Plan denied your request. The Plan says the requested bilateral facet 
joint injection does not meet the Medicare LCD coverage criteria. 
 
The Plan follows Medicare rules. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a bilateral facet joint injection. Our 
reviewer says that the requested bilateral facet joint injection is not considered medically necessary in this case. 
Our physician reviewer found that the enrollee is with complaints of low back pain. The enrollee has ongoing 
lumbar radiculopathy in both of the lower extremity to the feet. The magnetic resonance imaging (MRI) on 
May 12, 2023 reported severe bilateral L4-L5 facet hypertrophy and spinal stenosis. Medications include 
Tylenol. The enrollees diagnoses include lumbar degenerative joint disease, bilateral lower extremity 
radiculopathy. Physical exam demonstrated deep tendon reflexes normal, normal strength, normal tone, lumbar 
spinal tenderness. In this case, there is documentation of radiculopathy. The review has determined that the 
requested bilateral facet joint injections do not meet the Medicare LCD coverage criteria. 
 
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 bilateral facet joint injection have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a bilateral facet joint injection.
Appeal type: Lab
Decision: Partially Favorable

We decided that the Plan has to pay for 87801. We decided that the Plan does not have to pay for 87150,
87481, 87641, 87653, and 87798.

You asked the Plan to pay for procedure codes 87150, 87481, 87641, 87653, 87798, and 87801 rendered on
March 9, 2023.. You say that this should be paid for. The Plan says that the records do not support the services
billed.

We decided that the Plan has to pay for 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. The definition of the CPT 87801 is "Infectious
agent detection by nucleic acid (DNA or RNA), multiple organisms; amplified probe(s) technique."

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 for CPT 87801. Our reviewer says that the laboratory
report includes infectious agent detection, multiple organisms tested, amplified probe technique. Therefore, the
procedure is supported.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the services have been met. Therefore, we decided that the Plan has to pay for
87801.

We also decided that the Plan does not have to pay for 87150, 87481, 87641, 87653, and 87798.

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 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 for the rest of the codes. Our reviewer says that the
laboratory report does not include any documentation to verify the use of modifier XU for unusual nonoverlapping
services.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of 87150, 87481, 87641, 87653, and 87798 have not been met. Therefore, we
decided that the Plan does not have to pay for 87150, 87481, 87641, 87653, and 87798.

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake
and/or send us the new information. This does not happen often. If we decide to open the case again, we will
send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve for the elective left total reverse shoulder arthroplasty 
and acute inpatient hospital admission. 
 
You asked the Plan to pre-approve for an acute inpatient hospital admission. You say that the enrollee has done 
physical therapy as treatment for their left shoulder. You also say that the enrollee was not able to continue 
physical therapy due to it aggravating their shoulder pain. The Plan denied your request. The Plan says there is 
no documentation provided to support the expectation the enrollee will require a greater than 2 midnight stay. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 for an acute inpatient hospital 
admission. Our reviewer says that the documentation does not support that the criteria for inpatient admission 
are met in this case. Our physician reviewer found documentation is not evident regarding a significant past 
and/or current medical history that would place this enrollee at increased risk for peri-surgical complications 
requiring an inpatient stay.  There is no compelling rationale presented or extenuating circumstances noted to 
support the medical necessity of this request as an exception. Therefore, the record does not show that at the it 
is not reasonably expected that the enrollee's necessary hospital care would span two midnights. 
 
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 acute inpatient hospital admission have not been met. Therefore, we decided 
that the Plan does not have to pre-approve for the elective left total reverse shoulder arthroplasty and acute 
inpatient hospital admission.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87186 billed for date of service February 16, 
2023. 
 
You asked the Plan to pay for procedure code 87186. You say that this service was necessary and was reported 
appropriately. The Plan denied your request. The Plan says this code is 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. 
 
In this case, the CPT Code Manual definition of code 87186 is susceptibility studies, antimicrobial agent; 
microdilution or agar dilution (minimum inhibitory concentration [MIC] or breakpoint), each multi-
antimicrobial, per plate. 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for procedure code 87186. Our reviewer says that this code is not supported in this case. Our reviewer found the laboratory report does not include documentation of 
susceptibility studies. In this case, this procedure cannot be verified. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 87186 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 87186 billed for date of service February 16, 2023.