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

 
We decided that the Plan does not have to pay for procedure code 86077 billed for date of service June 10, 
2022. 
 
You asked the Plan to pay for procedure code 86077. You say that these services were reported correctly. The 
Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  In this case, the MUE for CPT code 86077 is 1. The MAI value for this code is 2. You billed 3 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 86077 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 86077 billed for date of service June 10, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a partial foot, shoe insert with longitudinal arch, toe 
filler (L5000). 
 
You asked the Plan to pre-approve foot orthotics. You say that the current shoe bottoms are slick and could 
cause a fall leading to an injury. You also say you have special shoe needs since the age of 7 and need them to 
walk. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve a partial foot, shoe insert with 
longitudinal arch, toe filler (L5000).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 86077 billed for date of service June 13, 
2022. 
 
You asked the Plan to pay for procedure code 86077. You say that these services were reported correctly. The 
Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  In this case, the MUE for CPT code 86077 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 86077 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 86077 billed for date of service June 13, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM) 
(K0554). 
 
You asked the Plan to pre-approve a Freestyle Libre CGM. You say that you have been using the Freestyle 
Libre for about 4 years and are new to this plan. Your diabetes is well controlled using this device. You would 
like to continue with this device. The Plan denied your request. The Plan says the request does not meet the 
Medicare or health plan coverage criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections or require frequent self-adjustment of insulin dosage based on the blood 
glucose testing results. Based on this information, we decided that Medicare rules for coverage of a Freestyle 
Libre CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle 
Libre continuous glucose monitor (CGM) (K0554).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the services requested are medically 
necessary. The Plan denied your request. The Plan says the member does not meet the Medicare criteria for 
LTACH services. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the medical record does not indicate that the enrollee requires services that she is not 
currently receiving. 
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88177 billed for date of service May 18, 
2022. 
 
You asked the Plan to pay for procedure code 88177. You say that this service was reported correctly. The Plan 
denied your request. The Plan says code 88177 is an add-on code which was billed without an appropriate 
primary procedure. 
 
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 
procedure code 88177 is an add-on code and has not been billed with an appropriate primary procedure code. 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 88177 billed for date of service May 18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve thermal destruction of the intraosseous basivertebral 
nerve for the first 2 vertebral bodies with imaging guidance, lumbar or sacral (CPT 64628). 
 
You asked the Plan to pre-approve thermal destruction of the intraosseous basivertebral nerve for the first 2 
vertebral bodies with imaging guidance, lumbar or sacral. You say that thermal destruction of the intraosseous 
basivertebral nerve for the first 2 vertebral bodies with imaging guidance, lumbar or sacral is medically 
necessary. The Plan denied your request. The Plan says thermal destruction of the intraosseous basivertebral 
nerve for the first 2 vertebral bodies with imaging guidance, lumbar or sacral 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 thermal destruction of the intraosseous 
basivertebral nerve for the first 2 vertebral bodies with imaging guidance, lumbar or sacral. Our reviewer says that the requested thermal destruction of the intraosseous basivertebral nerve for the first 2 vertebral bodies 
with imaging guidance, lumbar or sacral is not considered medically reasonable and necessary. Our physician 
reviewer found that this is considered an experimental/investigational procedure. Therefore, the request is 
deemed not medically reasonable and necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of thermal destruction of the intraosseous basivertebral nerve for the first 2 
vertebral bodies with imaging guidance, lumbar or sacral have not been met. Therefore, we decided that the 
Plan does not have to pre-approve thermal destruction of the intraosseous basivertebral nerve for the first 2 
vertebral bodies with imaging guidance, lumbar or sacral (CPT 64628).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 
You asked the Plan to pre-approve Prolia. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested drug does not meet step therapy criteria. 
 
 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Prolia. Our reviewer says that the 
documentation does not support that the requested drug meets step therapy criteria. Our physician reviewer 
found the enrollee has age related osteoporosis without osteoporotic fracture. The documentation does not 
support that there is a history of osteoporotic fracture or has tried and failed zoledronic acid. The 
documentation does not support that zoledronic acid would likely be less effective and/or likely have adverse 
effects for the enrollee. Therefore, the enrollee does not meet criteria for the requested drug. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve custodial care/home health services provided by a 
participating provider. 
 
You asked the Plan to pre-approve home health services. You say that you need these services. The Plan denied 
your request. The Plan says these services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from 
trained medical or paramedical staff, is not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of home health services have not been met. Specifically, we find that the services at issue in this case 
are considered custodial in nature. Therefore, we decided that the Plan does not have to pre-approve custodial 
care/home health services provided by a participating provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 78803 billed for date of service June 16, 
2022. 
 You asked the Plan to pay for procedure code 78803. You say that this service was reported correctly and 
should be paid. The Plan denied your request. The Plan says payment for code 78803 is bundled into payment 
for code 79445. 
 
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 78803 
is a column II code to column I code 79445. 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 78803 billed for date of service June 16, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on May 2, 2022. 
 
You asked the Plan to pay for the lab services. You say that you disagree with the Plan's denial. 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 May 2, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve posterior tibial neurostimulation (PTNS) (64566). 
 
You asked the Plan to pre-approve the outpatient service. You say that the enrollee needs this. The Plan denied 
your request. The Plan says the requested service is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that posterior tibial neurostimulation is medically 
necessary when the enrollee has demonstrated intolerance or failed treatment with 2 anticholinergic drugs. 
 
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 outpatient service. Our reviewer 
says that the requested PTNS is not medically necessary. Our physician reviewer found the provided 
documentation does not indicate the enrollee has failed treatment with 2 anticholinergic drugs. The reviewer 
found that the documentation does not indicate the enrollee has an intolerance to anticholinergic drugs. 
Therefore, the reviewer found that the requested PTNS 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 outpatient service have not been met. Therefore, we decided that the Plan 
does not have to pre-approve posterior tibial neurostimulation (PTNS) (64566).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve esophageal balloon distension study, diagnostic, with 
provocation when performed (EndoFLIP) (91040). 
 
You asked the Plan to pre-approve the EndoFLIP. You say that the requested procedure is an Food and Drug 
Administration (FDA) approved diagnostic tool for dysphagia. The Plan denied your request. The Plan says the 
requested service 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 the EndoFLIP. Our reviewer says that 
the requested EndoFLIP is not considered medically reasonable and necessary in this case. Our physician 
reviewer found the documentation indicates the enrollee does have dysphagia. The reviewer found that the 
documentation indicates that this treatment is being prescribed for an ulcer. Therefore, the reviewer found that 
the requested EndoFLIP 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 the EndoFLIP have not been met. Therefore, we decided that the Plan does not have to pre-approve esophageal balloon distension study, diagnostic, with provocation when performed 
(EndoFLIP) (91040).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia services (00840, & 99100) provided on December 
21, 2021. 
 
You asked the Plan to pay for the anesthesia services. You say that these services were medically necessary. 
The Plan denied your request. The Plan says coverage criteria has not been met. 
 
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 00840, & 99100 is not supported in the medical record. Specifically, the anesthesia is 
included in payment for the primary service. Based on this information, we decided that Medicare rules for 
coverage of the anesthesia services have not been met. Therefore, we decided that the Plan does not have to pay 
for anesthesia services (00840, & 99100) provided on December 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a genicular nerve block (64450, 64454). 
 
You asked the Plan to pre-approve the injections. You say that the enrollee needs these injections. You also say 
that the enrollee is not eligible for surgery. The Plan denied your request. The Plan says the requested 
injections 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 the injections. Our reviewer says that 
the requested genicular nerve blocks are not considered medically reasonable and necessary in this case. Our 
physician reviewer found this is considered an experimental or investigational procedure and is the subject of 
ongoing clinical trials. Therefore, the reviewer found that the requested genicular nerve block is not medically 
reasonable and necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the injections have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a genicular nerve block (64450, 64454).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous passive motion (CPM) exercise device for 
use on knee only (E0935x21). 
 
You asked the Plan to pre-approve a CPM device. You say that you disagree with the denial. The Plan denied 
your request. The Plan says Medicare states that there is insufficient evidence to justify coverage of these 
devices for longer periods of time or for other applications. The enrollee does not meet the Medicare or health 
plan coverage criteria. 
 
The Plan must follow Medicare rules. The rules say that coverage for CPM devices is limited to the three-week 
period following total knee replacement surgery during which the device is used in the home. 
 
Records show that knee replacement surgery was received on November 17, 2022. The file shows that a CPM 
device was used for three weeks following this surgery. Therefore, we decided that the Plan does not have to 
pre-approve a continuous passive motion (CPM) exercise device for use on knee only (E0935x21).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Group 3 power wheelchair with multiple power options 
(K0861). 
 
You asked the Plan to pre-approve the power wheelchair. You say that please review the attached medical 
documentation to support the need of the custom medical equipment being requested for the enrollee above. 
The Plan denied your request. The Plan says the current power wheelchair is less than 5 years old and still 
within reasonable useful lifetime. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that you have Group 3 power wheelchair single power option (K0856) which was received 
April 2021. The current Group 3 power wheelchair single power option (K0856) serves the same purpose as the current Group 3 power wheelchair. The current power wheelchair is still within the reasonable useful 
lifetime. Therefore, we decided that the Plan does not have to pre-approve Group 3 power wheelchair with 
multiple power options (K0861).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a ceramic/porcelain crown (D2740) and 
core buildup (D2950) provided on July 5, 2022. 
 
You asked the Plan to waive the copayment for a ceramic/porcelain crown (D2740) and core buildup (D2950). 
You say that you paid $1,280 and are entitled to be reimbursed $805. 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 $425 
copayment for a porcelain/ceramic crown (D2740). Your contract with the Plan also clearly says that porcelain 
and other tooth-colored materials on molars are considered a material upgrade with a maximum additional 
charge to the enrollee of $150. Your contract with the Plan also clearly says that name brand, laboratory 
processed, or in-office processed crowns/pontics produced through specialized technique or materials are 
material upgrades. The contract dentist may charge an additional fee not to exceed $325 in addition to the listed 
copayment. Your contract with the Plan also clearly says that enrollees must pay a $50 copayment for core 
buildup (D2950).  
 
You have been asked to pay a $425 copayment for a ceramic/porcelain crown (D2740). You have also been 
asked to pay a $150 fee for a material upgrade, and a $325 for material upgrades. You have also been asked to 
pay a $50 copayment for core buildup (D2950). This is a total of $950 ($425 + $150 + $325 + $50 = $950). 
This item/service falls within the dental services benefit category. Please note that the record shows the 
provider reimbursed the original $1,280 to you. 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 a 
ceramic/porcelain crown (D2740) and core buildup (D2950) provided on July 5, 2022.