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

 
We decided that the Plan does not have to pay for the next generation sequencing billed for date of service July 
6, 2022. 
 
You asked the Plan to pay for the billed services. You say that the codes are payable. The Plan denied your 
request. The Plan says one code must be submitted for the panel. 
 
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. The file shows that next generation sequencing was billed using 
multiple codes, including 81347. This 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 billed services have not been 
met. Therefore, we decided that the Plan does not have to pay for the next generation sequencing billed for date 
of service July 6, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve pneumatic compression devices (E0651, E0667) with a proprietary "Dual Wave" feature to be provided by an out-of-network (OON) provider.

You asked the Plan to pre-approve pneumatic compression devices. You say that the requested items are a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage for OON services have not been met.

Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan providers available to meet the enrollees' needs. The enrollee's contract with the Plan says that, with few exceptions, enrollees must use contract providers for care.

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 pneumatic compression devices. Our reviewer says that the requested items are not medically reasonable and necessary in this case. Our physician reviewer found that the provided medical records and a review of the current peer-reviewed medical literature do not document that use of the pneumatic compression devices with a "Dual Wave" feature has been shown in controlled studies to result in long-term health benefits and superiority over conventional devices in patients with lymphedema.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of pneumatic compression devices have not been met. Therefore, we decided that the Plan does not have to pre-approve pneumatic compression devices (E0651, E0667) with a proprietary "Dual Wave" feature to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet joint injections. 
 
You asked the Plan to pre-approve facet joint injections. You say that facet joint injections are medically 
necessary. The Plan denied your request. The Plan says the requested facet joint injections do not meet the 
Medicare LCD coverage criteria. 
 
The Plan follows Medicare rules. 
 
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 facet joint injections. Our reviewer says 
that the requested facet joint injections are not considered medically necessary in this case. Our physician 
reviewer found that the Medicare LCD requires two sets of diagnostic MBBs prior to an RFA. This has not 
been done; therefore, the request is deemed not medically reasonable and necessary 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 facet joint injections have not been met. Therefore, we decided that the Plan 
does not have to pre-approve facet joint injections.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on November 8, 2022, billed 
with codes 81314, 81345, and 81272. 
 
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. 

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 have 
not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
November 8, 2022, billed with codes 81314, 81345, and 81272.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous vertebral augmentation. 
 
You asked the Plan to pre-approve percutaneous vertebral augmentation. You say that the services are 
necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria 
has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that PVP and PVA will be considered reasonable and 
necessary for osteoporotic conditions when specific criteria are met. 
 
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 percutaneous vertebral augmentation. 
Our reviewer says that the services are not medically necessary. Our physician reviewer found there is not a 
clear impact on daily function that is related to the vertebral fracture, as there are multiple other plausible pain 
generators including at the lumbosacral spine. The fracture was not documented to be steroid induced. There is 
no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this 
request as an exception to guidelines. Therefore, the enrollee does not meet the coverage criteria detailed in the 
LCD. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of percutaneous vertebral augmentation have not been met. Therefore, we decided 
that the Plan does not have to pre-approve percutaneous vertebral augmentation.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bone graft at the time of implant placement (D6104). 
 
You asked the Plan to pre-approve a bone graft. You say that you need the bone graft before you get the 
implant. The Plan denied your request. The Plan says any dental service that is not listed as a covered code will 
not be covered, and you will be responsible for the full cost. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
bone graft at the time of implant placement (D6104).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 power wheelchair (PWC) with multiple power 
options (K0861), expandable controller (E2377), harness (E2313), electronic connection (E2311), and other 
related accessories.  

You asked the Plan to pre-approve a group 3 PWC with multiple power options and related accessories. You 
say that the items are medically necessary. The Plan denied your request. The Plan says the requested items are 
not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a group 3 PWC with multiple power options is 
considered medically necessary when the criteria listed in the Medicare Rules section is met. If a PWC base is 
denied, all related accessories will also be denied as not 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 group 3 PWC with multiple power 
options and related accessories. Our reviewer says that the member does not need these items. Our physician 
reviewer found the documentation does not indicate that the member has any pressure injuries or requires 
intermittent catheterization of the bladder or have spasticity that would necessitate power tilt or recline.  
Although the member's condition may meet criteria for a PWC, the criteria for this specifically requested PWC 
with multiple power options including power tilt and recline are not met. 
 
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 group 3 PWC with multiple power options and related accessories have not 
been met. Therefore, we decided that the Plan does not have to pre-approve a group 3 power wheelchair (PWC) 
with multiple power options (K0861), expandable controller (E2377), harness (E2313), electronic connection 
(E2311), and other related accessories.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a toggle switch (K0108) and an egg switch (K0108). 
 
You asked the Plan to pre-approve a toggle switch and an egg switch. You say that the requested items are 
medically necessary. The Plan denied your request. The Plan says that requested egg switch and toggle switch 
cannot be requested separately. 
 
The Plan must follow Medicare rules. Medicare rules say that code K0108 must not be used for any component 
or feature of an expandable controller at the time of initial issue. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of toggle switch and egg switch have not been met. The toggle switch and egg switch are part of the 
expandable controller and cannot be requested separately. Therefore, we decided that the Plan does not have to 
pre-approve a toggle switch (K0108) and an egg switch (K0108).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pneumatic propulsion tires (E2211 x 2), tube for 
pneumatic propulsion tire (E2212 x 2), and removable sideguards (K0108 x 2). 
 
You asked the Plan to pre-approve pneumatic propulsion tires, tube and removable sideguards. You say that the 
enrollee's current wheelchair is broken and cannot be repaired. You also say that the requested replacement chair is medically necessary for the enrollee. The Plan denied your request. The Plan says the requested 
components are not necessary for in home use. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is 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 pneumatic propulsion tires (E2211 x 2), tube for pneumatic propulsion tire (E2212 x 2), 
and removable sideguards (K0108 x 2).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a flexible protective covering system (L5962) for a 
lower-extremity prosthesis. 
 
You asked the Plan to pre-approve a flexible protective cover. You say that the requested item is a medical 
necessity for the enrollee. The Plan denied your request. The Plan says the requested item 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 flexible protective cover. Our reviewer says that the requested item is not considered medically reasonable and necessary in this case. Our physician reviewer found that although it is conceivable that the enrollee might have special circumstances that expose the enrollee's prosthesis to "unusually harsh environmental situations," absolutely no discussion of such circumstances can be found in the medical record or appeal documents submitted. There is no discussion of any specifically environmental damage to the enrollee's previous prosthesis (e.g., no mention of rust or penetrating coarse debris such as sand/dirt). 
 
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 flexible protective cover have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a flexible protective covering system (L5962) for a lower-extremity 
prosthesis.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 47120 and 35221 for date of service March 
22, 2022. 
 
You asked the Plan to pay for procedure codes 47120 and 35221. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the services billed are 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. 
 
We find that CPT code 47120 and 35221 is not supported in the medical record. Specifically, the operative 
report did not include documentation of a partial lobectomy and hepatectomy and resection of the liver; 
therefore, code 47120. In this case, we have confirmed that code 35221 is a column II code to column I code 
48150. This claim has not been billed with an appropriate modifier to bypass the edit. Based on this 
information, we decided that Medicare rules for coverage of procedure codes 47120 and 35221 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure codes 47120 and 35221 for date of 
service March 22, 2022.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve expandable controller (E2377) expandable controller harness 
(E2313) and electronic connection between wheelchair controller and two or more power seating system 
motors (E2311). 
 
You asked the Plan to pre-approve the upgraded electronics. You say that the denial states that this does not 
meet Medicare criteria, but you've received an approval from Medicare. The Plan denied your request. The 
Plan says that the enrollee does not meet Medicare criteria for the requested upgraded electronics. 
 
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 the upgraded electronics. Our reviewer 
says that the requested items/services are considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee is non-ambulatory and requires a power wheelchair for mobility and 
performing basic daily activities. The enrollee cannot perform pressure relief independently due to weakness 
and requires a power wheelchair with power tilt and recline for adequate pressure relief and positioning. The 
enrollee also requires power elevating leg rests for positioning of lower extremities. The complexity of the 
enrollee's seating and positioning needs necessitates a more complex group 3 power wheelchair base. The 
expandable controller with harness and electronic connection are necessary to operate the group 3 power 
wheelchair base and the three power options, including, tilt, recline and elevating leg rests, via a joystick. 
Therefore, the expandable controller (E2377) with harness (E2313) and electronic connection (E2311) is 
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 upgraded electronics have been met. Therefore, we decided that the Plan has 
to pre-approve expandable controller (E2377) expandable controller harness (E2313) and electronic connection 
between wheelchair controller and two or more power seating system motors (E2311).  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aid battery (V5266) provided on April 6, 2022. 
 
You asked the Plan to pay for this item. You say that you are requesting a reconsideration of the Plan's denial 
for payment. The Plan denied your request. The Plan says the item at issue is not a covered benefit. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case.   
 
We looked at this case file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of this item has not been met. Specifically, a hearing aid replacement battery is not a covered benefit. 
Therefore, we decided that the Plan does not have to pay for the hearing aid battery (V5266) provided on  
April 6, 2022.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for the outpatient hospital services billed with revenue codes 0250, 0258, 
0270, 0272, 0370, and 0710 provided on December 6, 2022. 
 
You asked the Plan to pay for the outpatient hospital services. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says that the services are not 
covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We find that outpatient services billed with revenue codes 0250, 0258, 0270, 0272, 0370, and 0710, are 
supported in the medical record. Specifically, per Medicare guidelines, CMS does not instruct hospitals on the 
assignment of HCPCS codes to revenue codes for services provided under OPPS. Based on this information, 
we decided that Medicare rules for coverage of the outpatient hospital services have been met. Therefore, we 
decided that the Plan has to pay for the outpatient hospital services billed with revenue codes 0250, 0258, 0270, 
0272, 0370, and 0710 provided on December 6, 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 laparoscopy, surgical, repair of paraesophageal hernia, 
includes fundoplasty, when performed; without implantation of mesh (43281). 
 
You asked the Plan to pre-approve laparoscopy, surgical, repair of paraesophageal hernia, includes fundoplasty, 
when performed; without implantation of mesh. 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. 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 laparoscopy, surgical, repair of 
paraesophageal hernia, includes fundoplasty, when performed; without implantation of mesh. 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 documentation in the medical records that this enrollee has a hiatal hernia 
repair that requires surgical repair at this time. Hiatal hernia repair at the time of gastric bypass is not 
determined to be 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 laparoscopy, surgical, repair of paraesophageal hernia, includes fundoplasty, 
when performed; without implantation of mesh have not been met. Therefore, we decided that the Plan does 
not have to pre-approve laparoscopy, surgical, repair of paraesophageal hernia, includes fundoplasty, when 
performed; without implantation of mesh (43281).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (99238) provided on August 8, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code is 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 99238 is "Hospital inpatient or observation discharge day 
management; 30 minutes or less on the date of the encounter". 
 
We find that CPT code 99238 is not supported in the medical record. Specifically, the records do not show that 
30 minutes or less of hospital discharge management services were provided on the date of service in question. 
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 the services (99238) provided on August 8, 2022.