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

 
We decided that the Plan does not have to pre-approve L2 kyphoplasty. 
 
You asked the Plan to pre-approve L2 kyphoplasty. You say that this is medically necessary. The Plan denied 
your request. The Plan says medical necessity coverage criteria is not met as the pain is multifactorial with 
multilevel disc disease. 
 
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 L2 kyphoplasty. Our reviewer says that 
the enrollee does not meet criteria for coverage. Our physician reviewer found there is no trial of bracing. More 
conservative measures are 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 L2 kyphoplasty have not been met. Therefore, we decided that the Plan does not 
have to pre-approve L2 kyphoplasty.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve seven home physical therapy visits. 

You asked the Plan to pre-approve home health services. You say that you are requesting reconsideration of the 
denied authorization. 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 
enrollee does not have documented, ongoing, home health physical therapy needs. The enrollee is functioning 
at a level appropriate for 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 home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve seven home physical therapy visits.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve intraoperative neuromonitoring and bone marrow 
aspirate for spine surgery. 
 
You asked the Plan to pre-approve intraoperative neuromonitoring and bone marrow aspirate. You say that 
your condition has become exasperating. The Plan denied your request. The Plan says the clinical value and 
effectiveness of these services have not been established. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. Medicare rules state that procedure codes with Status Code I are not valid for 
Medicare purposes and 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 intraoperative neuromonitoring and 
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 electroencephalography neuromonitoring 
is not needed for lumbar spine surgery and bone marrow aspirate is experimental. 
 
Additionally, the intraoperative neuromonitoring code 95941 has a Status Code of I so is not covered by 
Medicare. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of intraoperative neuromonitoring and bone marrow aspirate have not been met. 
Therefore, we decided that the Plan does not have to pre-approve intraoperative neuromonitoring and bone 
marrow aspirate for spine surgery.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric care from July 22, 2023, forward. 
 
You asked the Plan to pre-approve inpatient psychiatric care from July 22, 2023, forward. You say that the 
services at issue were medically necessary. The Plan denied your request. The Plan says the services at issue 
were not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient psychiatric care from July 22, 
2023, forward. Our reviewer says that the enrollee does not meet the criteria for treatment in an acute inpatient 
mental health treatment beyond the date in question of July 22, 2023, forward. Our physician reviewer found 
the enrollee did not require inpatient mental health treatment beyond July 22, 2023, as she was not a danger to 
herself or others and did not have any delusions, auditory or visual hallucinations. It did not appear that active 
treatment was taking place beyond the date in question. It did not appear that the services for the dates in 
question were reasonably expected or medically necessary to improve the enrollees condition or for the 
purpose of diagnosis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient psychiatric care from July 22, 2023, forward have not been met. 
Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric care from July 22, 2023, 
forward.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve open implantation of hypoglossal nerve neurostimulator array, 
pulse generator, and distal respiratory sensor electrode or electrode array (64582). 
 
You asked the Plan to pre-approve open implantation of hypoglossal nerve neurostimulator array, pulse 
generator, and distal respiratory sensor electrode or electrode array. You say that these services are medically 
necessary. The Plan denied your request. The Plan says that the criteria for coverage of this service are not met; 
the records do not show that you have a total blockage in the area behind the roof of the mouth. In addition, 
there is no documentation to support that you are regularly using your CPAP machine but are experiencing 
failure or intolerance. 
 
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 open implantation of hypoglossal nerve 
neurostimulator array, pulse generator, and distal respiratory sensor electrode or electrode array. 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 diagnosis of obstructive sleep apnea (OSA). You have undergone 
septoplasty and inferior turbinate reduction. You were evaluated by a Pulmonary and Sleep Medicine specialist 
on March 22, 2023. It is documented that you have "a history of severe OSA intolerant to CPAP." Your BMI is 
documented to be 27.4. A drug-induced sleep endoscopy performed on April 19, 2023, demonstrated anterior 
posterior collapse; however, there was no concentric collapse of the oropharyngeal tissues. The documentation in the case file supports that the coverage criteria for hypoglossal nerve neurostimulation have been met in this 
case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of open implantation of hypoglossal nerve neurostimulator array, pulse generator, 
and distal respiratory sensor electrode or electrode array have been met. Therefore, we decided that the Plan 
has to pre-approve open implantation of hypoglossal nerve neurostimulator array, pulse generator, and distal 
respiratory sensor electrode or electrode array (64582).  
 
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 bone marrow aspirate (20939). 
 
You asked the Plan to pre-approve a bone marrow aspirate. You say that this 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 a 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 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 enrollee's medical condition. No compelling rationale is 
presented, or extenuating circumstances noted to support the medical necessity of this request as an exception. 
 
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 bone marrow aspirate have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a bone marrow aspirate (20939).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81345 billed for date of service January 3, 
2023. 
 
You asked the Plan to pay for procedure code 81345. You say that the clinical documentation supports medical 
necessity. The Plan denied your request. The Plan says payment for code 81345 is bundled into payment for 
code 0089U. 
 
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 81345 is a column II code to column I code 0089U. Code 81345 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 81345 
billed for date of service January 3, 2023.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99366 billed for date of service January 31, 
2023, to February 21, 2023. 
 
You asked the Plan to pay for procedure code 99366. You say that you are requesting reconsideration for 
services advising a referral was provided prior to the date of service. The claims should be paid. The Plan 
denied your request. The Plan says procedure code 99366 is considered bundled and not separately payable.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99366 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99366 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99366 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99366 billed for date of service January 31, 2023, to February 21, 2023.
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 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 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 no compelling rationale is presented or extenuating circumstances noted to support the medical necessity of this request as an exception. Therefore, the request for 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ViviGen allograft (20931). 
 
You asked the Plan to pre-approve ViviGen allograft. You say that this is medically necessary. The Plan denied 
your request. The Plan says there is insufficient reliable evidence in the form of high-quality peer-reviewed 
medical literature to establish the safety and efficacy of the requested product for use in cervical fusion 
procedures.  
 
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 ViviGen allograft. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is limited published, large-scale, long-term peer-reviewed literature that shows 
this request to be an effective and/or safe treatment for the noted pathology. Further studies are needed to 
corroborate that the requested allograft would be as safe or better than standard allograft procedures. There is 
no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this 
request as an exception. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of ViviGen allograft have not been met. Therefore, we decided that the Plan does 
not have to pre-approve ViviGen allograft (20931).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone marrow aspirate for spine surgery. 
 
You asked the Plan to pre-approve bone marrow aspirate. You say that the enrollee needs this to have a better 
quality of life. 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. 
 
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 bone marrow aspirate is experimental when used as bone graft material in spine surgery. 
 
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 for spine surgery.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve alveoloplasty (D7311). 
 
You asked the Plan to pre-approve alveoloplasty. You say that the service is medically necessary. The Plan 
denied your request. The Plan says the requested service is not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
alveoloplasty (D7311).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic pathogen testing provided on November 22, 
2022, billed with codes 87632, U0003, and U0005. 
 
You asked the Plan to pay for the genetic testing billed. You say that this was medically necessary.  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 was an 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 pathogen testing 
provided on November 22, 2022, billed with codes 87632, U0003, and U0005.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87899 and 87900 billed for date of service 
November 29, 2022. 
 
You asked the Plan to pay for the billed services. You say that the testing was medically necessary. The Plan 
denied your request. The Plan says the codes are not supported in the medical records. 

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 87899 is infectious agent antigen detection by 
immunoassay with direct optical (i.e., visual) observation; not otherwise specified. The definition of code 
87900 is infectious agent drug susceptibility phenotype prediction using regularly updated genotypic 
bioinformatics. 
 
We find that CPT codes 87899 and 87900 is not supported in the medical record. The records do not contain 
sufficient information to show the services were provided as billed. 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 codes 87899 and 87900 billed for date of service November 29, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve L2 and L4 kyphoplasty (22514, 22515). 
 
You asked the Plan to pre-approve L2 and L4 kyphoplasty. You say that this is medically necessary. The Plan 
denied your request. The Plan says medical necessity coverage criteria is not met as the pain is multifactorial 
with multilevel disc disease. 
 
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 L2 and L4 kyphoplasty. Our reviewer 
says that the enrollee does not meet coverage criteria. Our physician reviewer found detailed 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 the enrollee's daily activities. 
Moreover, there is magnetic resonance imaging corroboration of retropulsion at the L4 level. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of L2 and L4 kyphoplasty have not been met. Therefore, we decided that the Plan 
does not have to pre-approve L2 and L4 kyphoplasty (22514, 22515).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric care from July 10, 2023, forward. 
 
You asked the Plan to pre-approve inpatient psychiatric care from July 10, 2023, forward. You say that the 
services at issue were medically necessary. The Plan denied your request. The Plan says the services at issue 
were not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient psychiatric care from July 10, 
2023, forward. Our reviewer says that the enrollee does not meet the criteria for treatment in an acute inpatient 
mental health treatment beyond the date in question of July 10, 2023, forward. Our physician reviewer found 
the enrollee did not require inpatient mental health treatment beyond July 10, 2023, as he was not a danger to 
himself or others and did not have any delusions, auditory or visual hallucinations. It did not appear that active 
treatment was taking place beyond the date in question. It did not appear that the services for the dates in 
question were reasonably expected or medically necessary to improve the enrollees condition or for the 
purpose of diagnosis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient psychiatric care from July 10, 2023, forward have not been met. 
Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric care from July 10, 2023, 
forward.