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

We decided that the Plan does not have to pre-approve an Orios allograft.

You asked the Plan to pre-approve an Orios allograft. You say that you are requesting reconsideration of the
denied authorization. The Plan denied your request. The Plan says that medical studies have not proven that the
use of this product during spinal surgery is better than the standard allograft products.

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 Orios allograft. 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 limited published, large-scale, long-term peer-reviewed literature that shows this
requested allograft to be an effective and/or safe treatment for the noted pathology. Further studies are needed
to demonstrate this request has beneficial outcomes compared with conventional treatment. There is no
compelling rationale presented or extenuating circumstances noted to support the medical necessity of this
request as an exception. Therefore, the requested Orios allograft, in this case, 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 Orios allograft have not been met. Therefore, we decided that the Plan does not
have to pre-approve an Orios allograft.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiological services provided on August 25, 2022, billed 
with code 93978. 
 
You asked the Plan to pay for the radiology services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says documentation does not support 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 93978 is Duplex scan of aorta, inferior vena cava, iliac 
vasculature, or bypass grafts; complete study. 
 
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 radiology services provided. Our reviewer says that 
documentation does not support the billed code. Our reviewer found that the medical documentation does not 
support the use of 93978, there is a more appropriate radiology code that is to the highest specificity. 
 
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 radiology services provided have not been met. Therefore, we decided that 
the Plan does not have to pay for radiological services provided on August 25, 2022, billed with code 93978.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87900 and 87899 billed for date of service 
December 21, 2022. 
 
You asked the Plan to pay for procedure codes 87900 and 87899. You say that these services were necessary 
and are supported in the medical record. The Plan denied your request. The Plan says these services are not 
supported in the medical record. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for procedure codes 87900 and 87899. Our reviewer says that 
these services are not documented in the medical records provided. Our reviewer found There are no results or 
a report in the record supporting that antigen detection with direct optical observation or drug susceptibility 
testing was performed. The reported codes 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 codes 87900 and 87899 have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure codes 87900 and 87899 billed for date of service December 21, 
2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from June 17, 
2022, through June 22, 2022. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the acute inpatient hospital care provided was 
not medically necessary.  
 
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 pay for the acute inpatient hospital care provided 
from June 17, 2022, through June 22, 2022. Our reviewer says that the documentation does not support that the 
criteria for inpatient payment are met in this case. Our physician reviewer found that the enrollee was admitted 
with chest pain. He was found to be COVID-19 positive, in the setting of lung cancer. The enrollee was stable 
and aggressive treatment for his cancer was not provided. The enrollee appears to have been stable for 
discharge, but this was delayed for non-medical reasons. Ongoing inpatient level of care was not medically 
necessary after June 17, 2022.  
 
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 acute inpatient hospital care provided from June 17, 2022, through June 22, 
2022 have not been met. Therefore, we decided that the Plan does not have to pay for the acute inpatient 
hospital care provided from June 17, 2022, through June 22, 2022.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pay for the plerixafor (J2562) provided on September 4, 2022.  
 
You asked the Plan to pay for the plerixafor. You say that the medication was medically necessary for the 
enrollee's treatment. The Plan denied your request. The Plan says that that prior authorization was not obtained. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise 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 pay for the plerixafor. Our reviewer says that the 
plerixafor was medically necessary. Our physician reviewer found plerixafor is approved by the Food and Drug 
Administration (FDA) for the mobilization of hematopoietic stem cells to the peripheral blood (in combination 
with granulocyte colony-stimulating factor [filgrastim]) for collection and subsequent autologous 
transplantation in those with non-Hodgkin lymphoma and multiple myeloma. The reviewer found that the 
documentation indicates the enrollee with multiple myeloma was undergoing an autologous peripheral stem 
cell transplant and the drug was used according to FDA guidelines. Therefore, the reviewer found that the 
service was reasonable and 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 plerixafor have been met. Therefore, we decided that the Plan has to pay for 
the plerixafor (J2562) provided on September 4, 2022.   
 
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: DME/ Orthotics
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve the upgraded electronics. We decided that the Plan does not have 
to pre-approve the seat elevator feature.  
 
You asked the Plan to pre-approve a Group 3 power wheelchair with multiple power options and accessories, 
including upgraded electronics and seat elevator feature.. You say that there are three power actuators that were 
already approved by CMS as meeting criteria. You also say that this is necessary for the enrollee.  The Plan 
says that the seat elevator does not serve a primary medical purpose and is statutorily non-covered. The Plan 
also says there is not a medical need to control these power options through the joystick. 
 
We decided that the Plan has to pre-approve the upgraded electronics.  
 
The Plan follows 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 the upgraded electronics and seat 
elevator feature. Our reviewer says that the requested upgraded electronics are medically necessary. Our 
physician reviewer found the provided documentation indicates the enrollee has a 3/5 motor strength in the 
upper extremities, impaired trunk control and a suprapubic catheter. Therefore, the reviewer found that the 
upgraded electronics are medically reasonable and 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 upgraded electronics and seat elevator feature have been met. Therefore, we 
decided that the Plan has to pre-approve the upgraded electronics.  
 
We also decided that the Plan does not have to pre-approve the seat elevator feature. 
 
The Plan follows Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose. 
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve the seat elevator feature. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for electrodes used during intraoperative neuromonitoring 
provided on May 27, 2022, billed with code A4556. 
 
You asked the Plan to pay for the electrodes as billed. You say that these services should be paid.  The Plan 
denied your request. The Plan says the neuromonitoring was approved for payment; however, no separate 
payment ca be made for the electrodes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
Code A4556 has a status indicator of P in the Physician Fee Schedule. This means that if the code is covered 
incident to a physician service, payment is bundled with those physician services. Based on this information, 
we decided that Medicare rules for coverage of the electrodes as billed have not been met. Therefore, we 
decided that the Plan does not have to pay for electrodes used during intraoperative neuromonitoring provided 
on May 27, 2022, billed with code A4556.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 95937, 95886, 95887, and 95907 billed for 
date of service September 2, 2021. 
 
You asked the Plan to pay for the billed services. You say that the services were considered medically 
necessary. The Plan denied your request. The Plan says the codes cannot be verified. 
 
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 find that CPT codes 95937, 95886, 95887, and 95907 are considered bundled and not separately payable. 
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 95937, 95886, 95887, and 
95907 billed for date of service September 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services and sodium ferric gluconate complex 
in sucrose injection related to end-stage renal disease (ESRD) provided on December 7, 2022, to December 26, 
2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services and sodium ferric gluconate complex in 
sucrose injection. You say that you disagree with the Plan's denial. The Plan denied your request. The Plan says 
Medicare does not separately pay for ESRD-related laboratory testing and injectable drugs. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services and sodium ferric gluconate complex in sucrose injection 
related to end-stage renal disease (ESRD) provided on December 7, 2022, to December 26, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 86703 billed for date of service July 25, 
2022. 
 
You asked the Plan to pay for procedure code 86703. You say that this service is supported in the medical 
record. The Plan denied your request. The Plan says this code is not supported in the medical record, and the 
service provided would be better reported with a different 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 86703 is antibody; HIV-1 and HIV-2, single result. 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 86703. Our reviewer says that the code 
reported is not supported in this case. Our reviewer found the laboratory report describes an HIV Ag/Ab 
combination test. In this case, there is a more appropriate code to report for service documented, and therefore, 
CPT code 86703 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 86703 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 86703 billed for date of service July 25, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services denoted by code 81292 provided on June 10, 
2022. 
 
You asked the Plan to pay for the lab services. You say that you have correctly billed the services at issue. 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 denoted by code 81292 provided on June 10, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99291 billed for date of service July 19, 
2022. 
 
You asked the Plan to pay for procedure code 99291. You say that you have correctly billed the services at 
issue. The Plan denied your request. The Plan says the provided records do not support the service 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 99291 is: Critical care, evaluation and management of the 
critically ill or critically injured patient; first 30-74 minutes. 
 
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 99291. Our reviewer says that procedure 
code 99291 does not meet criteria for payment. Our reviewer found that the provided medical records do not 
support the use of a critical-care visit as the documentation requirements have not been met to properly support 
this code. There is a more appropriate code that should be used. 
 
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 99291 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 99291 billed for date of service July 19, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from October 27, 2022, to 
November 25, 2022. 
 
You asked the Plan to pay for the home health services. You say that you would like the Plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says the NOA was not received timely. As 
such, this final claim was correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is September 27, 2022. The NOA was not received by the Plan until 
December 30, 2022. As more than 30 days passed between the timely filing date and the NOA receipt, no 
payment can be made on this claim. Therefore, we decided that the Plan does not have to pay for the home 
health services provided from October 27, 2022, to November 25, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pre-approve Signatera Residual Disease (MRD) Testing (81479). You asked the Plan to pre-approve Signatera MRD testing. You say that this test is medically necessary. The 
Plan denied your request. The Plan says that the criteria for coverage of this test are not met in this case. 
 
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 Signatera MRD testing. Our reviewer 
says that the requested items/services are considered medically reasonable and necessary in this case. Our 
physician reviewer found that the conditions of National Coverage Determination are fulfilled as the enrollee 
has advanced melanoma and plans on being treated for said cancer, and has not been previously tested with the 
same test for the same genetic content. The identification of recurrence or progression of disease within the 
intended use population of the test is identified in the National Comprehensive Cancer Network (NCCN) or 
other established guidelines as a condition that requires a definitive change in patient management. This test 
has been shown to demonstrate progression before clinical or radiographical evidence of progression and 
demonstrates superior sensitivity and specificity with significant lead time as compared to radiographical 
methods. The clinical validity of this test has been published in literature, and the enrollees condition of 
advanced melanoma and intended use with measuring response to immunotherapy were used in the clinical 
trials. The requested test meets Medicare criteria and is considered medically reasonable and necessary 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 Signatera MRD testing have been met. Therefore, we decided that the Plan has 
to pre-approve Signatera Residual Disease (MRD) Testing (81479).  
 
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 codes 87653, 87651, 87481, 87641, 87591, and 
87491 billed for date of service September 15, 2022. 
 
You asked the Plan to pay for procedure codes 87653, 87651, 87481, 87641, 87591, and 87491. You say that 
you disagree with the Plan's denial. The Plan denied your request. The Plan says payment for codes 87653, 
87651, 87481, 87641, 87591, and 87491 are 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 
87653, 87651, 87481, 87641, 87591, and 87491 are column II codes to column I code 87801. The medical 
records provided do not show that the services billed with the -59 modifier is a distinct procedural service. 
Based on this information, we decided that Medicare rules for coverage of services billed with a -59 modifier 
have not been met. 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 87653, 87651, 87481, 87641, 87591, and 87491 
billed for date of service September 15, 2022.