Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cupping therapy (97139) provided on August 13, 2022. 
 
You asked the Plan to pay for the cupping therapy. You say that the services should be paid. The Plan denied 
your request. The Plan says the cupping therapy was 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 pay for the cupping therapy. Our reviewer says that 
the cupping therapy is not considered medically reasonable and necessary in this case. Our physician reviewer 
found the documentation indicates that the enrollee received cupping therapy as part of physical therapy 
treatment for low back pain. The reviewer found there is a lack of robust medical literature supporting this 
treatment as this time. There is some medical literature indicating that it may be effective in reducing low back 
pain, but definitive conclusions cannot be made due to the low to moderate level of quality of the evidence. 
Therefore, the reviewer found that the cupping therapy 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 cupping therapy have not been met. Therefore, we decided that the Plan 
does not have to pay for the cupping therapy (97139) provided on August 13, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 95861 and 95870 billed for date of service 
September 12, 2022. 
 
You asked the Plan to pay for procedure codes 95861 and 95870. You say that these services are supported in 
the medical record as billed. The Plan denied your request. The Plan says the payment for codes 95861 and 
95870 is included in the payment for code 51785. Although a modifier was used in this case, the medical 
records provided do not support the use of this modifier. 
 
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 95861 
and 95870 is a column II code to column I code 51785; however, 95861 and 95870 was billed with a modifier.  
 
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 procedure codes 95861 and 95870. Our reviewer says that 
the documentation does not meet the criteria to report codes 95861 and 95870 with the 59 modifier. Our 
reviewer found code 95861 is not supported as the documentation does not specify where the needles were 
placed, just that they corresponded to the operative levels. This code is used when 5 or more muscles are tested 
in an extremity. It cannot be verified that 5 or more muscles were tested in bilateral extremities as the muscles 
tested were not documented. Code 96870 is also not supported. The operative report indicates that this code 
was used to report transcranial motor evoked potentials (TMEP). However, code 95870 is used for limited 
studies of the extremities. There is a more specific code to report TMEP. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 95861 and 95870 have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure codes 95861 and 95870 billed for date of service September 
12, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a vacuum pump (L5781). 
 
You asked the Plan to pre-approve a vacuum pump. You say that the durable medical equipment (DME) is 
necessary for the enrollee. The Plan denied your request. The Plan says the request for this residual limb 
volume management system exceeds the enrollee's need and does not meet the Medicare criteria of reasonable 
and 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 vacuum pump. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found per independent literature review the vacuum assisted socket system (VASS) added to a below 
knee prosthesis does not reliably improve gait performance. This item is not medically necessary, as it is not the standard of care and not beneficial when compared to usual 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 a vacuum pump have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a vacuum pump (L5781).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bag hooks (K0108). 
 
You asked the Plan to pre-approve bag hooks. You say that the power wheelchair and accessories are medically 
necessary. The Plan denied your request. The Plan says this item does not serve a medical purpose. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve bag hooks (K0108).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost sharing for the atezolizumab injection, the two 
bevacizumab injections, and the administration of the injections provided on June 21, 2022. 
 
You asked the Plan to waive the cost sharing for the injections and the administrations. You say that you do not 
understand the cost sharing applied to these services. The Plan denied your request. The Plan says this cost 
sharing was charged correctly. 

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay a 20% 
coinsurance for all other Medicare-covered Part B drugs, and a 20% coinsurance for each Medicare-covered 
chemotherapy drug and the administration of that drug. 
 
You have been asked to pay a $708.90 coinsurance for the two bevacizumab injections and the administrations 
of the injections ($3544.57 allowed amount x .20 = $708.90 rounded down). You have also been asked to pay a 
$325 copayment for the atezolizumab injection because the Plan is only holding you responsible for this 
amount, which is less than the 20% coinsurance. These items/services fall within the Medicare Part B 
prescription drugs benefit category.  
 
You have been asked to pay a total cost share of $1033.90 for the atezolizumab injection, the two bevacizumab 
injections, and the administration of the injections. This means that you have been asked to pay the correct 
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay 
when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the cost sharing for 
the atezolizumab injection, the two bevacizumab injections, and the administration of the injections provided 
on June 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the chiropractic treatments provided from 
August 10, 2022, to September 23, 2022. 
 
You asked the Plan to waive the copayment for the chiropractic treatments. You say that you think that you 
should only be responsible for one copayment. The Plan denied your request. The Plan says this cost sharing 
was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay a $20 
copayment for each Medicare-covered chiropractic visit. 
 
You have been asked to pay a $160 copayment for the chiropractic treatments ($20 x 8 visits = $160). These 
items/services fall within the chiropractic services benefit category. This means that you have been asked to 
pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you 
agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the 
copayment for the chiropractic treatments provided from August 10, 2022, to September 23, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the MRI, spinal canal and contents, lumbar; without 
contrast material (72148). 
 
You asked the Plan to pre-approve the MRI. You say that the MRIs are medically necessary. The Plan denied 
your request. The Plan says the chart notes indicate there is no leg numbness and the tingling in the legs has 
been fixed with the help of physical therapy 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are 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 MRI. Our physician reviewer found 
the lumbar spine MRI is not medically needed. The records show that the symptoms have resolved with 
physical therapy. The clinical need for an MRI is 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 the MRI have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the MRI, spinal canal and contents, lumbar; without contrast material (72148).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on July 28, 2022. 
 
You asked the Plan to pay for the lab services. You say that you would like the Plan to reconsider their denial 
of payment. The Plan denied your request. The Plan says you billed with an incorrect place of service on the 
claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on July 28, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the swallowing function radiologic examination, upper 
gastrointestinal tract radiologic examination, and the motion fluoroscopic evaluation of swallowing function by 
cine or video recording provided on November 2, 2022. 
 
You asked the Plan to pay for the swallowing function radiologic examination, upper gastrointestinal tract 
radiologic examination, and the motion fluoroscopic evaluation of swallowing function by cine or video 
recording. You say that you disagree with the Plan's denial. The Plan denied your request. The Plan says the 
services rendered are not a covered benefit in this place of service. 
 
The Plan must follow Medicare rules. Medicare rules say that Procedures requiring special technical 
competency and/or special equipment or materials are excluded when provided as a portable x-ray service. 
 
We looked at the file and Medicare rules. The studies were performed at a nursing home. These studies 
provided are not covered as portable x-ray service. Based on this information, we decided that Medicare rules 
for coverage of the swallowing function radiologic examination, upper gastrointestinal tract radiologic 
examination, and the motion fluoroscopic evaluation of swallowing function by cine or video recording have 
not been met. Therefore, we decided that the Plan does not have to pay for the swallowing function radiologic 
examination, upper gastrointestinal tract radiologic examination, and the motion fluoroscopic evaluation of 
swallowing function by cine or video recording provided on November 2, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve Intensity modulated radiation treatment (IMRT) (G6015 x8) and 
computed tomography (CT) guidance for placement of radiation therapy (77014 x8). 
 
You asked the Plan to pre-approve IMRT (G6015 x20) and CT guidance for placement of radiation therapy 
(77014 x20). You say that the services are necessary. The Plan denied your request. The Plan says that medical 
necessity has not been established. Therefore, coverage criteria have not been met. 
 
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 IMRT and CT guidance for placement 
of radiation therapy. Our reviewer says that the requested items/services are considered medically reasonable 
and necessary in this case. Our physician reviewer found NCCN guidelines do not specify dose to regional 
lymph nodes. The enrollee's lymph nodes should be dosed per dose histogram. The physician has provided 
appropriate rationale for 28 doses. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IMRT and CT guidance for placement of radiation therapy have been met. 
Therefore, we decided that the Plan has to pre-approve Intensity modulated radiation treatment (IMRT) (G6015 
x8) and computed tomography (CT) guidance for placement of radiation therapy (77014 x8).  
 
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: Partially Favorable

 
We decided that the Plan has to pay for the services described by procedure code(s) 87150, 87798, 87481, 
87801, 87481, 87799, 80053, G0471, 84443 and 85025. We decided that the Plan does not have to pay for the 
services described by procedure code(s) 80050.  
 
You asked the Plan to pay for laboratory services provided on October 21, 2022. You say that these services 
were necessary and are supported as billed. The Plan says that these services must be billed with a single code. 
 
We decided that the Plan has to pay for the services described by procedure code(s) 87150, 87798, 87481, 
87801, 87481, 87799, 80053, G0471, 84443 and 85025.  
 
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. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan did not make an appeal decision for the codes listed in this 
section. The Plan is not allowed to reopen any determinations while an appeal is pending and must issue a 
determination on all appealed services within the appeal time frame. As the Plan forfeited its opportunity to 
provide a denial rationale for these services, we find that the denial of payment is not supported. Therefore, we 
decided that the Plan has to pay for the services described by procedure code(s) 87150, 87798, 87481, 87801, 
87481, 87799, 80053, G0471, 84443 and 85025.  
 
We also decided that the Plan does not have to pay for the services described by procedure code(s) 
80050. 
 
The Plan must follow Medicare rules. The rules say that code 80050 (general health panel) is considered a non-
covered code. 
 
You have requested payment for services billed under code 80050. Medicare does not cover or pay for services 
billed under this code. Therefore, we decided that the Plan does not have to pay for the services described by 
procedure code(s) 80050. 
 
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 an injection of sclerosant; multiple incompetent veins 
(36471 x1) and injections of sclerosant; single incompetent vein (36470 x2). 
 
You asked the Plan to pre-approve an injection of sclerosant; multiple incompetent veins and injections of 
sclerosant; single incompetent vein. 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 invasive procedures will be considered medically 
reasonable and necessary if the patient meet certain criteria. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve an injection of sclerosant; multiple 
incompetent veins and injections of sclerosant; single incompetent vein. Our reviewer says that the services are not medically necessary. Our physician reviewer found the medical records do not show names of other veins 
which need treatment, if they have reflux and dates of treatment. The review has determined that 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 an injection of sclerosant; multiple incompetent veins and injections of 
sclerosant; single incompetent vein have not been met. Therefore, we decided that the Plan does not have to 
pre-approve an injection of sclerosant; multiple incompetent veins (36471 x1) and injections of sclerosant; 
single incompetent vein (36470 x2).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve procedure codes E2311, and K0108 x 6. 
 
You asked the Plan to pre-approve E2311, and K0108 x 6. You say that the enrollee's physical therapy records 
have been provided to show medical necessity. The Plan denied your request. The Plan says the gel pads do not 
serve a medical purpose and are not covered. The Plan says upgraded electronics are not medically necessary. 
The Plan says footplates, mounting hardware, and calf pads are already included with the approved items and 
cannot be covered separately. 
 
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 E2311, and K0108 x 6. Our reviewer says that procedure codes E2311, and K0108 x 6 are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the provided documentation indicates that the enrollee has adequate upper 
body strength to manage and cognition to manage standard power drive switches. The reviewer also found that 
the items represented by procedure code K0108 are not supported in the records. Therefore, the reviewer found 
that procedure codes E2311 and K0108 are 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 E2311, and K0108 x 6 have not been met. Therefore, we decided that the Plan 
does not have to pre-approve procedure codes E2311, and K0108 x 6.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the use of osteopromotive allograft (20930). 
 
You asked the Plan to pre-approve osteopromotive allograft. You say that the requested services are a medical 
necessity for the enrollee. The Plan denied your request. The Plan says the requested services are 
experimental/investigational. 
 
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 osteopromotive allograft. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that osteopromotive allograft is not medically needed for this routine lumbar fusion 
case. Iliac crest autograft is the gold standard. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of osteopromotive allograft have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the use of osteopromotive allograft (20930).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service August 17, 
2022. 

You asked the Plan to pay for procedure code 99100. The Plan denied your request. The Plan says procedure 
code 99100 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 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. 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 
99100 billed for date of service August 17, 2022.