Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the enrollee does not meet the criteria for admission to an IRF.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee is medically stable. There are no acute rehab nursing needs identified or 
documented. Document does not support necessity for admission to an IRF. The complexity of the enrollee's 
medical, rehab, and nursing needs does not require an acute hospital inpatient rehab stay with an 
interdisciplinary approach to rehabilitative care. The enrollee's rehab needs can be safely provided in an 
alternate and low intensity setting such as in a skilled nursing 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genicular nerve radiofrequency ablation. 
 
You asked the Plan to pre-approve genicular nerve radiofrequency ablation. You say that genicular nerve 
radiofrequency ablation is medically necessary. The Plan denied your request. The Plan says the requested 
genicular nerve radiofrequency ablation is not medically necessary. The Plan say that the Plan cannot approve 
until efficacy of this procedure has been established. 
 
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 genicular nerve radiofrequency 
ablation. Our reviewer says that the requested genicular nerve radiofrequency ablation is not considered 
medically reasonable and necessary. Our physician reviewer found that this procedure is considered 
experimental/investigational and is the subject of ongoing clinical trials. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of genicular nerve radiofrequency ablation have not been met. Therefore, we 
decided that the Plan does not have to pre-approve genicular nerve radiofrequency ablation.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 96365, 96366, 96521, and J1817 for date of 
service March 1, 2023. 
 
You asked the Plan to pay for procedure codes 96365, 96366, 96521, and J1817. You say that you disagree 
with the Plan's denial. The Plan denied your request. The Plan says the services are not payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that the evidence is adequate to conclude that 
outpatient intravenous (IV) insulin therapy (OIVIT) does not improve health outcomes in Medicare 
beneficiaries. 
 We looked at the file and Medicare rules. Review of the file shows that the services at issue were for OIVIT. 
OIVIT is not covered. Based on this information, we decided that Medicare rules for coverage of procedure 
codes 96365, 96366, 96521, and J1817 have not been met. Therefore, we decided that the Plan does not have to 
pay for procedure codes 96365, 96366, 96521, and J1817 for date of service March 1, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an additional 50 routine transportation trips (A0120). 
 
You asked the Plan to pre-approve an additional 50 routine transportation trips. You say that you need 
transportation for medical appointments. The Plan denied your request. The Plan says this request will exceed 
the maximum number of transportation trips allowed per year. 
 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 100 trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that this request will exceed the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve an additional 50 routine transportation trips (A0120).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99204 billed for date of service May 5, 2023. 
 
You asked the Plan to pay for code 99204. You say that the medical notes show that 99204 is a distinct service 
The Plan denied your request. The Plan says code 99204 is not supported by the medical record. The records 
don't support a moderate level of decision making or the total time required of the code 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 99204 is Office or other outpatient visit for the evaluation 
and management of a new patient, which requires a medically appropriate history and/or examination and 
moderate level of medical decision making. When using time for code selection, 45-59 minutes of total time is 
spent on the date of the encounter. 
 
 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 code 99204. Our reviewer says that code 99204 is not 
supported by the medical record. Our reviewer found the medical records do not substantiate the level of 
decision making billed with this code. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 99204 have not been met. Therefore, we decided that the Plan does not 
have to pay for code 99204 billed for date of service May 5, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the BMP allograft (20930). 
 
You asked the Plan to pre-approve the BMP allograft. You say that this is medically necessary. The Plan 
denied your request. The Plan says this has not been shown to be better or safer than standard bone grafts. 
 
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 BMP 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 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. 
 
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 BMP allograft have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the BMP allograft (20930).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing services (80307, 83789) provided on June 8, 
2023. 
 
You asked the Plan to pay for drug testing. You say that these services were medically necessary and should be 
paid. The Plan denied your request. The Plan says code 83789 is not separately payable, and code 80307 is not 
supported in the records provided. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. Medicare rules also say that providers performing validity testing on urine specimens utilized for drug testing should not separately bill the validity 
testing. 
 
In this case, the CPT Code Manual definition of code 80307 is drug test(s), presumptive, any number of drug 
classes, any number of devices or procedures.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the drug testing services have not been met. Specifically, the records provided do not include test 
results for any presumptive or screening drug tests. Without these results, we cannot verify the services were 
provided as billed. In addition, we find that the testing described by code 83789 is not separately payable. We 
looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage 
of drug testing have not been met. Therefore, we decided that the Plan does not have to pay for drug testing 
services (80307, 83789) provided on June 8, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a collapsible power wheelchair (codes K0823 and 
E1028) and additional items and accessories (codes E2365 x2 and E0973 x2). 
 
You asked the Plan to pre-approve a collapsible power wheelchair and additional items and accessories. The 
Plan denied your request. The Plan says the enrollee does not meet the medical necessity for a powered 
wheelchair.  
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. The 
rules also state that for equipment to be covered, it must be appropriate and needed for use inside the home. 
 
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 collapsible power wheelchair and 
additional items and accessories. Our reviewer says that the enrollee does not meet the criteria for coverage. 
Our physician reviewer found the enrollee is able to walk 100 feet on a regular basis in the home. The family is 
requesting a power wheelchair for community access. Our reviewer also found that the enrollee does not 
require a power wheelchair to perform MRADLs in the home. 
 
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 collapsible power wheelchair and additional items and accessories have not 
been met. Specifically, the item at issue in this appeal has been requested for use outside of the home. Although 
this item may be helpful, neither Medicare nor the Plan covers equipment for use outside the home. Therefore, 
we decided that the Plan does not have to pre-approve a collapsible power wheelchair (codes K0823 and 
E1028) and additional items and accessories (codes E2365 x2 and E0973 x2).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87798, 87481, 87491, 87511, 87563, 87591, 
87640, 87653, 87661, and 81001 billed for date of service December 16, 2022. 
 
You asked the Plan to pay for procedure codes 87798, 87481, 87491, 87511, 87563, 87591, 87640, 87653, 
87661, and 81001. You say that you disagree with the Plan's denial. The Plan denied your request. The Plan 
says payment for codes 87798, 87481, 87491, 87511, 87563, 87591, 87640, and 87661 are bundled into 
payment for code 87801. Codes 87653 and 81001 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, we have confirmed that code 87798, 
87481, 87491, 87511, 87563, 87591, 87640, and 87661 are column II codes to column I code 87801. This 
claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, 
Medicare billing criteria have not been met. Codes 87563 and 81001 are not supported. Specifically, the 
documentation submitted did not include a signed physician order or signed laboratory requisition and a lab 
report or lab results for the billed tests. Therefore, we decided that the Plan does not have to pay for procedure 
codes 87798, 87481, 87491, 87511, 87563, 87591, 87640, 87653, 87661, and 81001 billed for date of service 
December 16, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87150, 87481, 87653, 87798, 87801, and 
87641 billed for date of service September 7, 2022. 
 
You asked the Plan to pay for procedure codes 87150, 87481, 87653, 87798, 87801, and 87641. You say that 
you disagree with the denial. The Plan denied your request. The Plan says payment for codes 87150, 87481, 
87653, 87798, 87801, and 87641 is bundled into payment for code 87500. 
 
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 
87150, 87481, 87653, 87798, 87801, and 87641 are column II codes to column I code 87500. This claim has 
not been billed with an appropriate modifier to bypass the edit. The -XU modifier is not supported as a separate 
and distinct procedural service. 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 87150, 87481, 87653, 87798, 
87801, and 87641 billed for date of service September 7, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service April 15, 
2023. 
 You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 
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 70450 
is a column II code to column I code 70496. This claim 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 70450 billed for date of service April 15, 2023.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve vacuum assisted socket system (VASS) (L5781). 
 
You asked the Plan to pre-approve a VASS. You say that the services are necessary. The Plan denied your 
request. The Plan says that based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that socket replacements are considered reasonable and 
necessary if there is adequate documentation of functional and/or physiological need. 
 
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 VASS. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found any experienced clinician in this space 
knows that VASS is very much in the mainstream of standards of prosthetic care. Though Medicare policy is 
technically non-specific about coverage rules for VASS, it does in fact routinely cover it, meaning it cannot be 
on its face experimental. For you and many like you, this technology materially complies with the general 
reasonable and necessary criteria. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a VASS have been met. Therefore, we decided that the Plan has to pre-approve 
vacuum assisted socket system (VASS) (L5781).  
 
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 genetic testing provided on March 9, 2023, billed with 
codes 81225, 81226, 81227, 81231, 81232, 81240, 81241, 81291, 81306, 81328, 81335, 81479, and 81238. 
 
You asked the Plan to pay for the genetic testing billed. 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. The file shows that a combined cardio and pharmacogenetics panel test was provided. We looked at the file and 
Medicare rules. This panel testing was not billed with a single 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 9, 2023, billed with codes 81225, 
81226, 81227, 81231, 81232, 81240, 81241, 81291, 81306, 81328, 81335, 81479, and 81238.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve a genicular artery embolization. 
 
You asked the Plan to pre-approve a genicular artery embolization. You say that the enrollee has ongoing pain, 
functional limitations, and limited response to previous treatments for osteoarthritis. You say that all minimally 
invasive treatments have failed. You also say that the enrollee's pain and functional limitations need to be 
addressed. The Plan denied your request. The Plan says that this is not medically necessary. 
 
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 a genicular artery embolization. Our 
reviewer says that the requested genicular artery embolization is considered medically reasonable and 
necessary in this case. Our physician reviewer found the provided documentation indicates that the enrollee has 
tried conservative treatments. The reviewer found this is a reasonable minimally invasive treatment for the 
enrollee's debilitating bilateral knee pain due to osteoarthritis. Therefore, the reviewer found that the requested 
genicular artery embolization is 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 a genicular artery embolization have been met. Therefore, we decided that the 
Plan has to pre-approve a genicular artery embolization.  
 
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 pre-approve a repeat transforaminal epidural steroid injection 
(TFESI) (64483, 64484).  
 
You asked the Plan to pre-approve a repeat TFESI. You say that the request is medically necessary. The Plan 
denied your request. The Plan says the injection is not medically necessary. The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a repeat TFESI. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the previous transforaminal epidural steroid injection on August 14, 2023 provided 50% relief 
of pain for only two weeks. The review has determined that the enrollee does not meet the LCD criteria for 
transforaminal epidural steroid injection. The repeat TFESI is not considered 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 a repeat TFESI have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a repeat transforaminal epidural steroid injection (TFESI) (64483, 64484).