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

 
We decided that the Plan does not have to pre-approve a Vertiflex Superion Interspinous device (22869, 
22870).  
 
You asked the Plan to pre-approve a Vertiflex Superion Interspinous device. You say that this treatment is 
considered safe and effective and is medically necessary for this enrollee. The Plan denied your request. The 
Plan says medical studies haven't proven this service/item is helpful for the treatment of the enrollee's health 
problem. 
 
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 Vertiflex Superion Interspinous 
device. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found current evidence based medical guideline and peer reviewed literature do not fully support the spinal decompression device procedure over the gold standard of 
lumbar laminectomy. There is a lack of large volume, long-term peer-reviewed outcome studies to support the 
use of this device for this enrollees medical condition as discussed above. Overall, there is no compelling 
rationale presented or extenuating circumstances noted to support the medical necessity of this request as an 
exception. Therefore, the requested Vertiflex Superion interspinous spacer at L3-4 and L4-5, 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 a Vertiflex Superion Interspinous device have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a Vertiflex Superion Interspinous device (22869, 22870).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 90837 for date of service January 27, 2023. 
 
You asked the Plan to pay for procedure code 90837. 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 providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 90837 is psychotherapy, 60 minutes with patient. 
 
We find that CPT code 90837 is not supported in the medical record. Specifically, this service was billed with 
diagnoses F33.2 (Major depressive disorder, recurrent severe without psychotic features) and F31.81 (Bipolar 
II disorder). These two diagnosis codes should not be billed together. This means the claim is not payable as 
billed.  
 Based on this information, we decided that Medicare rules for coverage of procedure code 90837 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure code 90837 for date of service 
January 27, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing billed with code 0241U for date of service 
March 1, 2023. 
 
You asked the Plan to pay for the genetic testing. 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 genetic testing 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing billed with 
code 0241U for date of service March 1, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient services (G0008, 90674) provided on December 
29, 2022. 
 
You asked the Plan to pay for the outpatient services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the claim cannot be paid as 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. 
 
We find that CPT codes G0008, & 90674 are not supported in the medical record. Specifically, the claim was 
not billed with condition code 65 or a FQHC payment code.  Based on this information, we decided that 
Medicare rules for coverage of the outpatient services have not been met. Therefore, we decided that the Plan 
does not have to pay for outpatient services (G0008, 90674) provided on December 29, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an additional eight physical therapy visits (97110). 
 
You asked the Plan to pre-approve the therapy services. You say that this is medically necessary. The Plan 
denied your request. The Plan says this is not medically necessary. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 therapy services. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of your 
condition. Our physician reviewer found you are able to continue with a home exercise program. The program 
with the therapist has limited efficacy and has not resolved your pain or limited range of motion despite 43 
sessions. Continued input from the skilled therapist is 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 the therapy services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an additional eight physical therapy visits (97110).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99220 billed for date of service August 6, 
2022. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says the billed code 
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 99220 is initial observation 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. 
 
We find that CPT code 99220 is not supported in the medical record. The records show that the enrollee was 
seen to have her auto defibrillator interrogated. The enrollee was not in acute distress and did not experience 
significant cardiac events. The records do not show medical decision making of high complexity. Based on this 
information, we decided that Medicare rules for coverage of the billed services have not been met. Therefore, 
we decided that the Plan does not have to pay for procedure code 99220 billed for date of service August 6, 
2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services for date of service July 9, 2022, to 
August 7, 2022. 
 You asked the Plan to pay for the home health services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the NOA was not received timely. As such, this final claim was 
correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is January 10, 2022. The NOA was not received by the Plan until August 7, 
2022. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for the home health services for 
date of service July 9, 2022, to August 7, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for self-administered drugs and unclassified drugs provided from 
January 4, 2023, to January 6, 2023. 
 You asked the Plan to pay for the self-administered drugs and unclassified drugs. The Plan denied your request. 
The Plan says the medication is not covered as a medical benefit under the Plan. The Plan also says Medicare 
rules state that providers must report services correctly. Providers must report services with the appropriate 
code. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Also, the unclassified drugs were not billed with the appropriate code. Therefore, we decided 
that the Plan does not have to pay for self-administered drugs and unclassified drugs provided from 
January 4, 2023, to January 6, 2023.  
 
Benefits for the self-administered drugs and unclassified drugs  may be available under Medicare Part D. 
Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal 
rights.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93010 billed for date of service January 6, 
2023. 
 
You asked the Plan to pay for procedure code 93010. You say that the enrollee had multiple exams on this date 
of service and the attached reports support this level of service. You say that the claim should be reconsidered 
for processing. The Plan denied your request. The Plan says payment for code 93010 is bundled into payment 
for code 31500. 
 
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 93010 
is a column II code to column I code 31500. 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 93010 billed for date of service January 6, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on June 24, 2022, billed with 
codes 81201, 81162, 81292, 81295, 81298, 81307, 81317, 81321, and 81351. 
 
You asked the Plan to pay for the genetic testing billed. You say that the treatment sought was medically 
necessary. 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 
code. We looked at the file and Medicare rules. The panel testing 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 
June 24, 2022, billed with codes 81201, 81162, 81292, 81295, 81298, 81307, 81317, 81321, and 81351.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for definitive drug testing (G0482) provided on December 20, 2022. 
 
You asked the Plan to pay for drug testing. You say that this service was reported correctly. The Plan denied 
your request. The Plan says that the code used to report the service provided is not supported in the medical 
record. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of 
code G0482 is drug test(s), definitive, 15-21 drug class(es), including metabolite(s) if performed. 
 
We find that CPT code G0482 is supported in the medical record. Specifically, the records provided show that 
drugs from 20 different drug classes were tested in this case. Based on this information, we decided that 
Medicare rules for coverage of drug testing have been met. Therefore, we decided that the Plan has to pay for 
definitive drug testing (G0482) provided on December 20, 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: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99053 billed for date of service October 18, 
2022. 
 
You asked the Plan to pay for procedure code 99053. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says procedure code 99053 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 99053 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99053 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99053 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99053 billed for date of service October 18, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair and accessories (K0861, E0953, 
E0955, E0960, E1007, E1012, E1028, E2300, E2311, E2313, E2323, E2361, E2377, E2607, E2620). 
 
You asked the Plan to pre-approve a power wheelchair and accessories. You say that the enrollee is a 
quadriplegic and 100% bed bound. He lacks the ability to do any type of functional weight shift. He requires a 
motorized wheelchair with the recline feature due to inability to reposition and inability to access the bathroom. 
He is currently diaper and catheter dependent. A standard power wheelchair will not allow his to independently 
perform his home mobility ADL's. without the appropriate equipment. The enrollee is a major risk of 
hospitalization and pressure ulcers. The Plan denied your request. The Plan says the request cannot be 
approved at this time by Medicare or the health plan. The enrollee may meet criteria for a simpler power 
wheelchair with power tilt but without a power recline option. As the enrollee does not qualify for the 
wheelchair base, none of the requested accessories can be covered. 
 
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.  
 
 
 
 
 
 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 power wheelchair and accessories. 
Our reviewer says that the service is not medically necessary. Our physician reviewer found the enrollee does 
not currently have skin issues or incontinence per the provider. He has adequate upper body strength to feed 
himself. Per record and L33789 as the enrollee does not require an expandable controller, he is not at high risk 
for skin breakdown, and does not use a catheter. He has a chronic condition and has intact skin. Power seat 
elevation is considered not medically necessary. The enrollee does not meet criteria for approval at this time. 
 
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 power wheelchair and accessories have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a power wheelchair and accessories (K0861, E0953, E0955, E0960, 
E1007, E1012, E1028, E2300, E2311, E2313, E2323, E2361, E2377, E2607, E2620).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from June 13, 2022, to July 
12, 2022.  
 You asked the Plan to pay for the home health services. You say that these services were billed correctly. The 
Plan denied your request. The Plan says the NOA was not received timely. As such, this final claim was 
correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is June 13, 2022. The NOA was not received by the Plan until July 28, 2022. 
As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be made on 
this claim. Therefore, we decided that the Plan does not have to pay for home health services provided from 
June 13, 2022, to July 12, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76706 billed for date of service October 27, 
2022. 
 
You asked the Plan to pay for the billed services. You say that the diagnosis code is correct for the procedure. 
The Plan denied your request. The Plan says coverage criteria have not been met. 
 
The Plan follows Medicare rules. The rules explicitly say that certain screening tests are only covered under 
certain medical indications.  
 
We looked at the file and the rules. In this case, there are insufficient medical records to show that the coverage 
criteria for the provided testing have been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 76706 billed for date of service October 27, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Qutenza 8% topical system. 
 
You asked the Plan to pre-approve Qutenza 8% topical system. You say that Qutenza 8% topical system is 
medically necessary for the enrollee. The Plan denied your request. The Plan says Qutenza 8% topical system 
is not being used for a medically accepted reason or is being off-label; therefore, they are unable to provide 
coverage for this drug. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
  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 Qutenza 8% topical system. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found Qutenza is indicated 
for the treatment of neuropathic pain associated with postherpetic neuralgia, and neuropathic pain associated 
with diabetic peripheral neuropathy of the feet. The use of Qutenza is not supported by one of the major drug 
compendia or by clinical research in a CMS-approved medical journal. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Qutenza 8% topical system have not been met. Therefore, we decided that the 
Plan does not have to pre-approve Qutenza 8% topical system.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve kyphoplasty procedures (22514, 22515). 
 
You asked the Plan to pre-approve kyphoplasty. You say that the requested services are a medical necessity for 
you. The Plan denied your request. The Plan says the requested services are 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 kyphoplasty. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that detailed documentation is not evident in the case record regarding imaging corroboration of an acute 
or subacute compression fracture at the L1 and L2 levels. You are not hospitalized, nor is there moderate to 
severe pain noted that is worsening. Progression of vertebral body height loss, greater than 25% vertebral body 
height reduction, or kyphotic deformity are not corroborated. 
 
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 procedures (22514, 22515).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve targeted genomic sequence analysis panel, solid organ 
or hematolymphoid neoplasm, DNA analysis, and RNA analysis when performed, 51 or greater genes (81455). 
 
You asked the Plan to pre-approve genetic testing. You say that the enrollee has lymphocytosis and increased 
granular t-cells. The testing is to check why these are increased. The concern is for a malignancy. The Plan 
denied your request. The Plan says the testing requested to be performed is not specified nor is there 
documentation in the medical records that targeted genetic testing was being requested. The enrollee does not 
meet the requirements for approval. 
 
The Plan must follow Medicare rules. Medicare rules say that NGS testing is reasonable and necessary when 
performed in a CLIA certified laboratory and when all requirements are met. 
 
We looked at the file and Medicare rules. The records show that there is no diagnosis of an advanced cancer or 
documentation to show that targeted testing was being requested. Additionally, there is no indication that a 
MoIDX technical assessment has been performed to meet the Medicare criteria. Based on this information, we 
decided that Medicare rules for coverage of genetic testing have not been met. Therefore, we decided that the 
Plan does not have to pre-approve targeted genomic sequence analysis panel, solid organ or hematolymphoid 
neoplasm, DNA analysis, and RNA analysis when performed, 51 or greater genes (81455).