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

 
We decided that the Plan does not have to pre-approve bone marrow aspirate to be used during lumbar fusion 
surgery. 
 
You asked the Plan to pre-approve bone marrow aspirate. You say that the patient is in a lot of pain and can 
barely walk at this time. The Plan denied your request. The Plan says the spinal surgery has been approved. 
However, the clinical value and effectiveness of bone marrow aspirate in the setting of spinal fusion surgery 
have not been demonstrated in peer-reviewed literature. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve bone marrow aspirate. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found bone marrow aspirate is considered experimental at this time. More research is needed to determine the appropriateness of bone marrow aspirate when used as bone graft material. 
 
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 to be used during lumbar fusion surgery.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance services received on March 
4, 2023. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that the ambulance being out 
of network is not your fault. The Plan denied your request. The Plan says this cost sharing was charged 
correctly.  
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $255 
copayment for ambulance services.  
 
You have been asked to pay $255 copayment for the ambulance services. This item/service falls within the 
ambulance services benefit category. This means that you have been asked to pay the correct amount based on 
your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled 
in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the ambulance 
services received on March 4, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial hospital care (procedure code 99223) rendered on July 
26, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says Current Procedural Terminology (CPT) code 99223 (1 Unit ) remains 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 99223 is "Initial hospital care, per day, for the evaluation 
and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination 
of care with other physicians, other qualified health care professionals, or agencies are provided consistent with 
the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring 
admission are of high severity.  Typically, 70 minutes are spent at the bedside and on the patient's hospital floor or unit." 
 
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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the history of present illness is 
straight-forward, and the overall history is not comprehensive. The assessment is not supported, and the 
medical decision making is not of high complexity.  As such, the billing of CPT 99223 is not supported. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for initial hospital care (procedure code 99223) rendered on July 26, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power seat elevation system (E2300) and an electronic
connection (E2310) for the enrollee.
You asked the Plan to pre-approve a power seat elevation system and an electronic connection. You say that
the wheelchair and accessories are medically necessary to meet the enrollee's current needs. The Plan denied
your request. The Plan says there is not a medical need to control a power option through the joystick.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for an electronic
connection. Our Medical Director states that the documentation supports that the enrollee's upper extremity
strength and function appear to be adequate to operate the Group 3 power wheelchair base and power tilt
feature with their own switches.
Our Medical director found that the enrollee's condition does not meet criteria for an electronic connection.
We looked at this physician's review, the file, and Medicare rules. A power seat elevation feature is noncovered
because it is not primarily medical in nature. Based on this information, we decided that Medicare
rules for coverage of a power seat elevation system and an electronic connection have not been met. Therefore,
we decided that the Plan does not have to pre-approve a power seat elevation system (E2300) and an electronic
connection (E2310) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 20526 billed for date of service February 15, 
2023.  
 You asked the Plan to pay for procedure code 20526. 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 claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 20526 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 20526 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 20526 billed for date of service February 15, 2023.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve continued use of a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that a home ventilator is a medical necessity for 
the enrollee. The Plan denied your request. The Plan says that a home ventilator is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not reasonable and necessary. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a home ventilator. Our reviewer says 
that a home ventilator is medically reasonable and necessary in this case. Our physician reviewer found that the 
enrollee has COPD with chronic respiratory failure and has been on Trilogy ventilator since 2021. The enrollee 
is compliant and tolerating the therapy. To revert to BiPAP would be step-down of therapy and not standard of 
care. Therefore, the current mode of treatment is indicated and best practice. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a home ventilator have been met. Therefore, we decided that the Plan has to 
pre-approve continued use of a home ventilator (E0466).  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 95873 billed for date of service March 7, 
2023.  
 
You asked the Plan to pay for procedure code 95873. You say that you believe this code is separately payable. 
The Plan denied your request. The Plan says payment for code 95873 is bundled into payment for code 95874. 
 
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 95873 is a column II code to column I code 95874 with a modifier indicator of 0. The column II code is therefore not 
payable. 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 95873 billed for date of service March 7, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99140 billed for date of service June 14, 
2022. 
 
You asked the Plan to pay for procedure code 99140. You say that you provided records to support payment. 
The Plan denied your request. The Plan says procedure code 99140 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 99140 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99140 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99140 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99140 billed for date of service June 14, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an intensive outpatient program (IOP). 
 
You asked the Plan to pre-approve an IOP. You say that the requested intensive outpatient program is 
medically necessary. The Plan denied your request. The Plan says it was determined that the authorization for 
admission to an intensive outpatient program (IOP), partial hospitalization program (PHP), denied correctly because this provider is a psychiatric hospital, which is not recognized as an independent provider type by 
Medicare that can provide intensive outpatient program (IOP), partial hospitalization program (PHP).  
 
The Plan must follow Medicare rules. Medicare rules say that an intensive outpatient program is covered when 
the criteria listed in the Medicare rules section of this decision are met.  
 
We looked at the file and Medicare rules. The file shows that the request is not for the covered PHP level of 
care, and that at this time, the IOP benefit category has been proposed but not yet finalized or implemented. 
Based on this information, we decided that Medicare rules for coverage of an IOP have not been met. 
Therefore, we decided that the Plan does not have to pre-approve an intensive outpatient program (IOP).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on March 31, 2023, billed with 
codes 81235, 81275, 81404, 81405, 81479-TC, 81479-26, 88346-59, and 88350. 
 
You asked the Plan to pay for the genetic testing billed. You say that this was medically necessary and should 
be paid. 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 testing provided on 
March 31, 2023, billed with codes 81235, 81275, 81404, 81405, 81479-TC, 81479-26, 88346-59, and 88350.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided on February 1, 2023. 
 
You asked the Plan to pay for the ambulance services. You say that this was not a duplicate because the patient 
is dual-eligible. The Plan denied your request. The Plan says this claim is a duplicate of a previously paid claim 
and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on March 1, 2023. Comparison of the two claims shows these are exact duplicates. 
There is no evidence presented to support that the billed items/services were provided twice on the same date. Based on this information, we decided that the Medicare rules for the ambulance services have not been met. 
Therefore, we decided that the Plan does not have to pay for ambulance services provided on February 1, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided on February 8, 2023. 
 
You asked the Plan to pay for the medical services. You say that the patient was seen by two providers on this 
date of service, and both visits should be payable. The Plan denied your request. The Plan says you billed an 
incorrect Place of Service code on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must bill the appropriate POS code for 
services.  POS code 21 indicates that the services were performed in an inpatient hospital setting. POS code 22 
indicates that the services were performed in an outpatient hospital setting. 
 
In this case, you billed the claim for these services with POS code 21.  However, the documentation shows that 
the patient was in an observation status.  Observation is an outpatient status, so POS code 22 should have been 
used on the claim instead. 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the medical services have not been met. Therefore, we decided that the Plan does not have to pay 
for medical services provided on February 8, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on March 21, 2023, by an 
out-of-network (OON) provider.  
 
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says this service 
is not covered when provided OON. 
 
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 requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the laboratory services provided on March 21, 
2023, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an electronic connection (E2311) for the enrollee.
You asked the Plan to pre-approve an electronic connection. You say that this is medically necessary for the
enrollee. The Plan denied your request. The Plan says that the member's upper limb strength and function are
adequate for the member to be able to control the power options using their own switches which are included in
the allowance of these power options.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for an electronic
connection. Our Medical Director states that the documentation supports that the enrollee's upper extremity
strength and function appear to be adequate to operate the power options using their own switches. Our
physician reviewer found that the enrollee's condition does not meet criteria for coverage of an electronic
connection. 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 electronic connection have not been met. Therefore, we decided
that the Plan does not have to pre-approve an electronic connection (E2311) for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on October 13, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that at this time, there is no 
contractual agreement that indicates that these tests are included in the dialysis rate. The Plan denied your 
request. The Plan says Medicare does not separately pay for ESRD-related laboratory testing. 
 
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 related to end-stage renal disease (ESRD) provided on October 
13, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure (64628, 64629). 
 
You asked the Plan to pre-approve an Intracept procedure. 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 an Intracept procedure. 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 magnetic resonance imaging (MRI) showing only modic changes without 
facet degenerative joint disease (DJD) or foraminal stenosis. The cause of the back pain is not clear.  
 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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Intracept procedure (64628, 64629).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an intensive outpatient program (IOP). 
 
You asked the Plan to pre-approve an IOP. You say that the requested intensive outpatient program is 
medically necessary. The Plan denied your request. The Plan says the authorization for admission to an 
intensive outpatient program (IOP), partial hospitalization program (PHP), denied correctly because this provider is a psychiatric hospital, which is not recognized as an independent provider type by Medicare that 
can provide intensive outpatient program (IOP), partial hospitalization program (PHP).  
 
The Plan must follow Medicare rules. Medicare rules say that an intensive outpatient program is covered when 
the criteria listed in the Medicare rules section of this decision are met.  
 
We looked at the file and Medicare rules. The file shows that the request is not for the covered PHP level of 
care, and that at this time, the IOP benefit category has been proposed but not yet finalized or implemented. 
Based on this information, we decided that Medicare rules for coverage of an IOP have not been met. 
Therefore, we decided that the Plan does not have to pre-approve an intensive outpatient program (IOP).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that admission into a long term acute care 
hospital is needed for recovery. The Plan denied your request. The Plan says admission into a long term acute 
care hospital 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 the enrollee is receiving appropriate care in current acute care setting as provided by 
the Health Plan. Documentation does not support that LTACH services are 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.