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

 
We decided that the Plan does not have to pre-approve open left sacroiliac (SI) joint fusion (27280). 
 
You asked the Plan to pre-approve open left SI joint fusion. You say that this is medically necessary. The Plan 
denied your request. The Plan says the clinical value and effectiveness of an open SI joint fusion in the absence 
of SI joint instability, fracture, or tumor have not been demonstrated in the peer-reviewed literature. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve open left SI joint fusion. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found detailed documentation is not evident regarding imaging or radiographic evidence 
supporting a sacroiliitis pathology. There is no clear history of SI joint pain onset or failure of conservative 
treatment directed to the SI joint. Multiple other plausible pain generators including at the lumbosacral spine 
are evident. There are limited large-scale, long-term references showing the safety and efficacy of the requested 
surgery in this clinical setting. 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 open left SI joint fusion have not been met. Therefore, we decided that the Plan 
does not have to pre-approve open left sacroiliac (SI) joint fusion (27280).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an assisted living visit provided on February 24, 2023. 
 
You asked the Plan to pay for an assisted living visit. You say that you are requesting a reconsideration of the 
denied charges. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for an assisted living visit 
provided on February 24, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87481, 87653, 87641, and 87150 billed for 
date of service May 11, 2022. 
 
You asked the Plan to pay for procedure codes 87481, 87653, 87641, and 87150. You say that you would like 
the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says payment for codes 
87481, 87653, and 87641 are bundled into payment for code 87801. Additionally, payment for code 87150 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 
87481, 87653, and 87641 are column II codes to column I code 87801. Additionally, we have confirmed that 
code 87150 is a column II code to column I code 87500. 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 codes 87481, 87653, 87641, and 87150 
billed for date of service May 11, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee is ready for admission to an IRF. The 
Plan denied your request. The Plan says an IRF admission is not medically necessary, and the enrollee's needs 
can be met at an alternate level of care.  
 
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 that the enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87491 billed for date of service March 1, 
2023. 
 
You asked the Plan to pay for the billed services. You say that the codes are approved by Medicare. The Plan 
denied your request. The Plan says the billed service 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.  

In this case, the CPT Code Manual definition of code 87491 is infectious agent detection by nucleic acid (DNA 
or RNA); Chlamydia trachomatis, amplified probe technique. We find that CPT code 87491 is not supported in 
the medical record. Specifically, the records provided do not show that this test was performed. Based on this 
information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 87491 billed for date of service March 1, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Respiratory PCR panel (87798, 87451) provided on 
January 2, 2022.   
 
You asked the Plan to pay for the laboratory service. You say that kindly process the claim towards payment. 
The Plan denied your request. The Plan says this service does not meet this requirement of the member's plan 
of benefits and is excluded from coverage.  
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file, and Medicare rules. The enrollee evaluated for an upper respiratory panel. A respiratory 
PCR panel tested for 40 pathogens. Based on this information, we decided that Medicare rules for coverage of 
the laboratory service have not been met. Therefore, we decided that the Plan does not have to pay for the 
Respiratory PCR panel (87798, 87451) provided on January 2, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81455 billed for date of service December 5, 
2022. 
 
You asked the Plan to pay for procedure code 81455. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says payment for code 81455 is bundled into payment for code 80053. 
 
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 81455 
is a column II code to column I code 80053. 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 81455 billed for date of service December 5, 
2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve BMP allograft (20930). 
 
You asked the Plan to pre-approve BMP allograft. 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 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 no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception. Therefore, the requested BMP allograft 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 BMP allograft have not been met. Therefore, we decided that the Plan does not 
have to pre-approve BMP allograft (20930).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve nine further months of home ventilator therapy. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are 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. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has chronic obstructive 
pulmonary disease (COPD) and has had a home ventilator since 2019. Recent compliance is 100 percent. The 
ventilator is being used in the average volume-assured pressure support (AVAPS) mode. Medicare does not 
cover a home ventilator when used at settings that can be provided with bi-level positive airway pressure 
(BiPAP).  The plan has approved the device for an additional three months, which allows time for transition to 
BiPAP. Nine further months of ventilator use are not 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve nine further months of home ventilator therapy.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for lab testing code 0117U billed for date of service November 23, 2022. 
 
You asked the Plan to pay for the billed services. You say that the testing identifies treatable causes of pain. 
The Plan denied your request. The Plan says that the code is a non-covered service. 
 
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. 
 
We looked at the file and the rules. The Local Coverage Article, A58812, the Plan used in their decision to 
deny services is not binding in this case. The ruling does not have jurisdiction in Kentucky where the services 
were provided. The Local Coverage Determination and Article (L38394 and A58324) that does have 
jurisdiction does not state that code 0117U is a non-covered service. The Plan has 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 lab testing 
code 0117U billed for date of service November 23, 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that IRF services are physically and medically necessary 
for the enrollee to return home at their maximum level of functioning with a decreased risk for readmission.  
The Plan denied your request. The Plan says the enrollee does not meet Medicare guidelines for services in 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 that the complexity of the enrollee's nursing, medical, and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the enrollee may have a need for physical 
therapy and/or occupational therapy, there is no documented need for intensive rehabilitation services. 
Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that 
the enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program 
provided in an IRF. 
 
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 an IRF admission and services.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance transport provided on March 18, 2023. 
 
You asked the Plan to pay for the ambulance transport and an emergency room visit. You say that the enrollee 
was transferred to another hospital. You also say that you are asking this appeal to be honored as the enrollee 
should not be responsible as the hospital did not have adequate staffing and would not allow his wife to drive 
him. 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). The enrollee's contract with the Plan clearly says that enrollees 
must pay a $275 copayment for each one-way Medicare-covered ambulance transport.  
 
The enrollee has been asked to pay a $275 copayment for the ambulance transport. This service falls within the 
ambulance services benefit category. This means that the enrollee has been asked to pay the correct amount 
based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay 
upon enrolling in the Plan. Therefore, we decided that the Plan does not have to pay for ambulance transport 
provided on March 18, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee is requiring acute rehabilitation with 
ongoing cardiac management and pain management. The Plan denied your request. The Plan says an IRF 
admission is not medically necessary, and the enrollee's needs can be met at an alternate level of care.  
 
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 that the enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88305 billed for date of service April 6, 
2023. 
 
You asked the Plan to pay for procedure code 88305. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says this code is included in the facility payment and is not separately 
payable.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that the specimen was taken while the enrollee was an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 1 for CPT code 88305. This means there 
is both a professional and technical component for the CPT code. In this case, an appropriate modifier to 
indicate the professional component has not been billed with CPT code 88305. Based on this information, we 
decided that Medicare rules for coverage of procedure code 88305 have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure code 88305 billed for date of service April 6, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laparoscopy (49653) and radical resection of tumor 
(21558) provided on November 11, 2022. 
 
You asked the Plan to pay for the surgical services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says certified surgical assistants are not reimbursable as assistants to 
surgeons. 
 
The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the 
procedure is covered for an assistant and the person who assists the surgery bears the designation of a 
physician, PA, NP, or CNS. 
 
In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of 
practitioners. Therefore, we decided that the Plan does not have to pay for the laparoscopy (49653) and radical 
resection of tumor (21558) provided on November 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99204) provided on September 30, 2022, by 
an out-of-network (OON) provider.  
 
You asked the Plan to pay for the physician service. You say that the enrollee needs to start treatment for an 
elevated prostate-specific antigen (PSA) and benign prostatic hyperplasia (BPH) to get the levels back to 
normal. You also say that due to the levels being elevated, you believe this to be of high importance for the 
enrollee to have been seen for this follow up visit. The Plan denied your request. The Plan says prior 
authorization was not obtained. 
 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 provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. 
We found no exception that would require the Plan to pay for the service. Therefore, we decided that the Plan 
does not have to pay for the office visit (99204) provided on September 30, 2022, 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 inversion table to be provided by a Medicare non-
participating provider. 
 
You asked the Plan to pre-approve inversion table. You say that this manufacturer is the only one with the 
equipment you need. The Plan denied your request. The Plan says this supplier does not participate in Medicare 
so is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that to receive payment for covered items or services, 
a provider or supplier must be enrolled in Medicare.  
 
We looked at the file and Medicare rules. This supplier is not enrolled in Medicare so is not covered. Based on 
this information, we decided that Medicare rules for coverage of inversion table have not been met. Therefore, 
we decided that the Plan does not have to pre-approve an inversion table to be provided by a Medicare non-
participating provider.