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

 
We decided that the Plan does not have to pre-approve Mastegraft allograft (20930). 
 
You asked the Plan to pre-approve Mastegraft allograft. You say that this is medically necessary. The Plan 
denied your request. The Plan says the medical necessity for the denied procedure/services has not been 
established after clinical review and per the peer reviewed medical 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 Mastegraft 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. Moreover, the documentation does 
not clearly indicate that this is to be used with autogenous bone marrow or autograft. 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 Mastegraft allograft have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Mastegraft allograft (20930).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee requires physical and 
occupational therapy five times a week to improve functional mobility and activities of daily living. The Plan 
denied your request. The Plan says an LTACH admission is not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee is improving and only requires short-term acute care at the current 
facility until they are more stable. The enrollee does not require services at the LTACH that are not already 
available at the current facility.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Barostim Neo device (C1825, 0266T). 
 
You asked the Plan to pre-approve a Barostim Neo device. 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 a Barostim Neo device. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there remains an absence of randomized, blinded clinical studies examining long-
term clinical outcomes establishing the value of Barostim Neo in patient management. As a result, at this time 
the Barostim Neo system would not be considered medically reasonable and necessary in this enrollees clinical management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a Barostim Neo device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Barostim Neo device (C1825, 0266T).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the influenza vaccine services provided on October 17, 2022. 
 
You asked the Plan to pay for the billed services. You say that the correct type of bill is 341. The Plan denied 
your request. The Plan says that a corrected claim with a valid type of bill is needed. 
 
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 denied services based on home health billing guidelines. The claim does not indicate the services 
were provided by a home health provider. The Plan offered no other rationale for their denial. The Plan has not 
made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny 
your request.  Therefore, we decided that the Plan has to pay for the influenza vaccine services provided on 
October 17, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab test codes 87653-XU, 87641-XU, 87481-XU, and 87150-
XU provided on December 15, 2022. 
 
You asked the Plan to pay for lab tests. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says these codes are 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 CPT code. 
 
In this case, the CPT Code Manual definition of code 87653-XU is infectious agent detection by nucleic acid; 
Streptococcus, group B, amplified probe technique. The CPT Code Manual definition of code 87641-XU is 
infectious agent detection by nucleic acid; Staphylococcus aureus, methicillin resistant, amplified probe 
technique. The CPT Code Manual definition of code 87481-XU Infectious agent detection by nucleic acid; 
Candida species, amplified probe technique. The CPT Code Manual definition of code 87150-XU is Culture, typing; identification by nucleic acid probe, amplified probe technique, per culture or isolate, each organism 
probed. 
 
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 lab tests. Our reviewer says that these codes do not meet 
criteria for payment. Our reviewer found medical documentation shows that 84781-XU is included in payment 
for code 87801, medical records do not indicate that this lab test was done on a separate sample from the one 
given by the enrollee and tested with procedure code 87801. Medical documentation shows that 87150 is 
included in 87500, medical records cannot verify that this lab was done as a separate and unique exam. 87641 
was not tested in the urinary tract infection (UTI) sample and therefore cannot be verified in the medical 
documentation. Medical records show that 87653 is included in 87801 so is not separately billable. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of lab tests have not been met. Therefore, we decided that the Plan does not have 
to pay for lab test codes 87653-XU, 87641-XU, 87481-XU, and 87150-XU provided on December 15, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (81292) provided on November 16, 2021. 
 
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 (81292) provided on November 16, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the requested SNF care is medically necessary for 
the enrollee. The Plan denied your request. The Plan says the requested care is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing 
facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Outpatient Therapies
Decision: Favorable

 
We decided that the Plan has to pre-approve additional physical therapy visits. 
 
You asked the Plan to pre-approve the physical therapy visits. The Plan denied your request. The Plan says that 
additional physical therapy visits are not medically necessary. 
 
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 has not substantiated their denial. Our physician reviewer 
found that the Plan has not sent records and the denial places and undue burden on the enrollee.Therefore, we 
decided that the Plan has to pre-approve additional physical therapy visits.  
 
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 kyphoplasty (22514). 
 You asked the Plan to pre-approve kyphoplasty. 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 PVA (percutaneous vertebroplasty (PVP) or 
kyphoplasty (PKP)) is covered in patients who meet specific criteria. 
 
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 kyphoplasty. Our reviewer says that the 
services are not medically necessary Our physician reviewer found there is no trial of bracing. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of kyphoplasty have not been met. Therefore, we decided that the Plan does not 
have to pre-approve kyphoplasty (22514).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips (A0120). 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that you disagree with the 
denial and request reconsideration. The Plan denied your request. The Plan says additional trips would exceed 
your benefit limit. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 36 trips per year.  
 
We looked at your request, the records in the case file, and the rules. The records show that you have used 
thirty-two (32) one-way transportation trips out of the allowed thirty-six (36) one-way trips approved. Once 36 
trips are used, the benefit will be exhausted. Based on this information, we decided that the Plans rules for 
coverage of routine transportation have not been met. Therefore, we decided that the Plan does not have to pre-
approve additional routine transportation trips (A0120).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panel testing billed for date of service August 18, 2022. You asked the Plan to pay for the billed services. You say that the testing is not covered. The Plan denied your 
request. The Plan says the claims are related to the lab services ordered. 
 
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 looked at the file and the rules. The records do not show why the panel testing was needed above the 
standard urine culture or urinalysis. The panel testing was also not billed with a single code as required. 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 the panel testing billed for date of service August 
18, 2022.
Appeal type: Transportation
Decision: Favorable

 
We decided that the Plan has to pay for ambulance service, basic life support, emergency transport and ground 
mileage provided on December 14, 2022. 
 
You asked the Plan to pay for the ambulance service, basic life support, emergency transport and ground 
mileage. You say that without the ambulance transport your mother would not have been able to get the care 
she needed. You also ask that you reverse your denial of the ambulance transport. The Plan denied your 
request. The Plan says that the services are non-covered charges. 
 
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 patient care report (PCR) for the date of service in question is 
not identified. The Plan made no attempt to obtain the PCR for this trip. As such, the Plan has failed to support 
its denial. Therefore, we decided that the Plan has to pay for ambulance service, basic life support, emergency 
transport and ground mileage provided on December 14, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory testing identified with code 0117U for date of 
service October 25, 2022. 
 
You asked the Plan to pay for the laboratory testing identified with code 0117U. You say that you disagree 
with the Plan's denial. The Plan denied your request. The Plan says the claim for this molecular pathology 
testing did not include the required unique identifier. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of the laboratory testing 
identified with code 0117U have not been met. Therefore, we decided that the Plan does not have to pay for the 
laboratory testing identified with code 0117U for date of service October 25, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 64999 provided on March 8, 2023. 
 
You asked the Plan to pay for procedure code 64999. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not supported. 
 
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 64999 is Unlisted procedure, nervous system. 
 
We find that CPT code 64999 is not supported in the medical record. Specifically, the record is not clear what procedure on the nervous system was performed to support procedure code 64999. Based on this information, 
we decided that Medicare rules for coverage of procedure code 64999 have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 64999 provided on March 8, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for various tests (82306, 84153, 86141, 93308, 93882, 93979, 
94010, 94761, 95921, 95922, 95923) provided on October 17, 2022. You asked the Plan to pay for various tests. You say that these services are supported in the medical record. 
The Plan denied your request. The Plan says the claim information indicates that these services were performed 
as part of a general medical exam without abnormal findings. These services were provided as screenings 
which are not covered by Medicare. In addition, some of the codes billed are bundled services. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, various tests, was requested solely for screening purposes. Medicare does not 
cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for 
various tests (82306, 84153, 86141, 93308, 93882, 93979, 94010, 94761, 95921, 95922, 95923) provided on 
October 17, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Vivigen allograft for spinal surgery. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says Medicare does not cover experimental and investigational 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 the services. Our reviewer says that the 
requested 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 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. Therefore, the requested Vivigen 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Vivigen allograft for spinal surgery.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pontic-porcelain fused to high noble metal for tooth number 24 (D6240).

You asked the Plan to pre-approve this dental item. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says your benefit for the requested item has already been exhausted.

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, certain limitations apply. The record shows your benefit for the requested item has been exhausted. Specifically, the Plan's contract says that up to four units of fixed dentures are covered each year.

The Plan previously approved four retainer crowns for teeth number 22, 23, 26, and 27. Therefore, you have exhausted the allowable benefit for the requested dental item at this time. Therefore, we decided that the Plan does not have to pre-approve a pontic-porcelain fused to high noble metal for tooth number 24 (D6240).