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

 
We decided that the Plan does not have to pay for procedure code 93010 billed for date of service September 9, 
2022. 
 
You asked the Plan to pay for procedure code 93010. You say that you disagree with the denial. The Plan 
denied your request. The Plan says payment for code 93010 is bundled into payment for code 12002.  
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 12002. 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 September 9, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the home ventilator (CPT code E0466). 
 
You asked the Plan to pre-approve the home ventilator. You say that the ventilator is necessary. The Plan 
denied your request. The Plan says the request for a home mechanical ventilator set in average volume-assured 
pressure support (AVAPS) mode with Auto-expiratory positive airway pressure (EPAP) (AE) that could be 
delivered by bilevel positive airway pressure (BiPAP) is not covered. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the home ventilator. Our physician 
reviewer found the enrollee is not being treated for COPD and does not have a history of COPD or smoking.  
There are no pulmonary function tests. There is no diagnosis of thoracic restrictive disease or neuromuscular 
disease. This enrollee may benefit from CPAP or BiPAP during sleep, as treatment for obesity hypoventilation 
syndrome (OHS). This has not been tried and shown to fail as an outpatient. Medicare does not cover a home ventilator when used as BiPAP, or in the treatment of OHS. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the home ventilator (CPT code E0466).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve lift mechanism (CPT code E0627), lift chair furniture 
portion and heat and massage upgrade (A9270 X2). 
 
You asked the Plan to pre-approve the items. You say that you have severe difficulty without a seat lift. The 
Plan denied your request. The Plan says you do not meet criteria for a seat lift mechanism. 
 The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions 
listed in the Medicare rules section 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 the items. Our physician reviewer 
found the documentation is insufficient and does not support the request for the seat lift mechanism per 
Medicare's LCD L33801. 
 
We looked at this physician's review, the file, and Medicare rules. Although a seat lift chair may be 
appropriate, Medicare does not cover this item and the Plan must provide coverage only for items that 
Medicare covers. Furthermore, the heat and massage upgrade 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. Based on this information, we decided that Medicare rules for coverage of the items have not been met. 
Therefore, we decided that the Plan does not have to pre-approve lift mechanism (CPT code E0627), lift chair 
furniture portion and heat and massage upgrade (A9270 X2).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of the VIA disc allograft during spinal surgery. 
 
You asked the Plan to pre-approve the VIA disc allograft. You say that it is felt that this would be a beneficial 
treatment. The Plan denied your request. The Plan says this remains experimental at this time. 
 
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 VIA disc allograft. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the VIA disc allograft remains experimental for use in spine surgery. More research 
is needed. 
 
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 VIA disc allograft have not been met. Therefore, we decided that the Plan 
does not have to pre-approve use of the VIA disc allograft during spinal surgery.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Truxima. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not covered. 
 The Plan must follow Medicare rules. the rules say that Original Medicare is responsible for the costs 
associated with clinical trials. 
 
We looked at the file and Medicare rules. The file shows that the services at issue are requested as part of a 
clinical trial. These services are not covered by the Plan but by Original Medicare. Therefore, we decided that 
the Plan does not have to pre-approve Truxima.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve power wheelchair itself and the other requested 
items/accessories. (CPT code(s): K0856, K0108, K2620, E2607, E2377, E2361, E2313, E2311, E1028, E1012, 
E1002, E0955). 
 
You asked the Plan to pre-approve the DME. You say that the DME is medically necessary. The Plan denied 
your request. The Plan says the DME is not medically necessary. 
 
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 the DME. Our physician reviewer 
found the enrollee has a neurologic disorder with functional deficits. Criteria for a power wheelchair are met. 
The documentation does not indicate that the enrollee has any pressure injuries or requires intermittent 
catheterization of the bladder that would necessitate power tilt or recline. Although criteria for a power 
wheelchair are met, the criteria for the specifically requested power wheelchair 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 the DME have not been met. Therefore, we decided that the Plan does not have 
to pre-approve power wheelchair itself and the other requested items/accessories. (CPT code(s): K0856, 
K0108, K2620, E2607, E2377, E2361, E2313, E2311, E1028, E1012, E1002, E0955).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 2 continuous glucose monitor (CGM) 
and supplies. 
 
You asked the Plan to pre-approve a Freestyle Libre 2 CGM and supplies. 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 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. Based on this information, we decided that Medicare rules for coverage of a 
Freestyle Libre 2 CGM and supplies have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a Freestyle Libre 2 continuous glucose monitor (CGM) and supplies.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the RFA (CPT code 64625). 
 
You asked the Plan to pre-approve the RFA. You say that the service is medically necessary. The Plan denied 
your request. The Plan says the clinical value and effectiveness of radiofrequency ablation to the sacroiliac (SI) 
joint in the setting of sacroiliitis have not been demonstrated in the peer-reviewed literature. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the RFA. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found SI joint RFA remains experimental. More research is needed. 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 RFA have not been met. Therefore, we decided that the Plan does not have to pre-approve the RFA (CPT 
code 64625).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a complete denture - maxillary (D5110), and complete 
denture - mandibular (D5120) provided on September 12, 2022. 
 
You asked the Plan to pay for the complete denture - maxillary (D5110), and complete denture - mandibular 
(D5120).       The Plan denied your request. The Plan says these services are not covered under the benefit 
package. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans 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 pay for a 
complete denture - maxillary (D5110), and complete denture - mandibular (D5120) provided on September 12, 
2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the fusion surgery (20931, 22551, 22845 and 22853). 
 
You asked the Plan to pre-approve the fusion surgery. You say that the services are medically necessary. The 
Plan denied your request. The Plan says the 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 the fusion surgery. 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 of adequate conservative measures for neck pain including 
a recent 6-12 week trial of physical therapy (PT). There are no red flags for surgery 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 the fusion surgery have not been met. Therefore, we decided that the Plan does not have to pre-
approve the fusion surgery (20931, 22551, 22845 and 22853).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code P9603 billed for date of service April 14, 2022. 
 
You asked the Plan to pay for code P9603. You say that you provided medical records to support payment. The 
Plan denied your request. The Plan says the records do not support the service 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 P9603 is Travel allowance one way in connection with 
medically necessary laboratory specimen collection drawn from home bound or nursing home bound patient; 
prorated miles traveled . 
 
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 code P9603. Our reviewer says that code P9603 is not 
supported in the medical record. Our reviewer found the medical record does not include documentation of 
travel, and therefore cannot be verified. Travel is not documented to confirm miles traveled and units billed. 
 
 We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code P9603 have not been met. Therefore, we decided that the Plan does not 
have to pay for code P9603 billed for date of service April 14, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services rendered from October 7, 2021, to 
November 5, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the claim was not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that a RAP and a claim must be submitted for all episodes 
for which Medicare makes payment based on HIPPS codes. 
 
We looked at the file and Medicare rules. The file shows that a valid RAP was not submitted for the services at 
issue. Based on this information, we decided that Medicare rules for coverage of these services have not been 
met. Therefore, we decided that the Plan does not have to pay for the home health services rendered from 
October 7, 2021, to November 5, 2021.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for the arthroscopy (CPT code 29823) provided on August 12, 2022. 
 
You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. 
The Plan says that the service is not supported by the records. 
 
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 29823 is arthroscopy, shoulder, surgical; debridement, extensive, 3 or more discrete structures (eg, 
humeral bone, humeral articular cartilage, glenoid bone, glenoid articular cartilage, biceps tendon, biceps 
anchor complex, labrum, articular capsule, articular side of the rotator cuff, bursal side of the rotator cuff, 
subacromial bursa, foreign body[ies]). 
 
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 the service. Our reviewer says that the documentation does 
support CPT 29823: arthroscopy, shoulder, surgical, debridement, extensive 3 or more discrete structures (e.g., 
humeral bone, humeral articular cartilage, glenoid bone, glenoid articular cartilage, biceps tendon, biceps 
anchor complex, labrum, articular capsule, articular side of the rotator cuff, bursal side of the rotator cuff, 
subacromial bursa, foreign body[ies]). 
  
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the service have been met. Therefore, we decided that the Plan has to pay for 
the arthroscopy (CPT code 29823) provided on August 12, 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the allograft (CPT code 20930). 
 
You asked the Plan to pre-approve the allograft. You say that fusion is needed because of the creation of 
iatrogenic instability following facetectomy of that motion segment. The Plan denied your request. The Plan 
says the service is unproven due to insufficient evidence of efficacy and/or safety. 
 
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 allograft. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found InFUSe bioactive allograft is experimental in spine surgery. More research is needed to show 
safety and efficacy. 
 
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 allograft have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the allograft (CPT code 20930).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the power seat elevation system (E2300) and 
expandable controller (E2377) with related electronic connection (E2311) and harness (E2313). 
 
You asked the Plan to pre-approve the power seat elevator and expandable controller with related components. 
You say that it is felt that all requested items should be approved. The Plan denied your request. The Plan says 
the power wheelchair was approved aside from the noncovered seat elevator and the medically unnecessary 
expandable controller. 
 
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 power seat elevator and expandable 
controller with related components. Our reviewer says that the expandable controller is not considered 
medically reasonable and necessary in this case. Our physician reviewer found records document that the 
enrollee has 4/5 bilateral upper extremity grip strength and normal finger to nose testing, thus indicating she 
has adequate upper extremity strength, coordination and function to operate the wheelchair's power options 
with their own switches.  
 
The E2300 power seat elevator is also noncovered by Medicare. 
 
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 power seat elevator and expandable controller with related components have 
not been met. Therefore, we decided that the Plan does not have to pre-approve the power seat elevation system 
(E2300) and expandable controller (E2377) with related electronic connection (E2311) and harness (E2313).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the definitive drug testing provided on August 3, 2022, billed 
with code G0483. 
 
You asked the Plan to pay for the definitive drug testing as billed. You say that this testing is medically 
necessary. The Plan denied your request. The Plan says this 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 G0483 is Drug test(s), definitive, utilizing (1) drug 
identification methods able to identify individual drugs and distinguish between structural isomers (but not 
necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, 
single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples 
(e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-
specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and 
mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or 
more drug class(es), including metabolite(s) if performed. 
 
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 the definitive drug testing as billed. Our reviewer says that 
the documentation does not support the intent of the ordering physician to order 22 or more drug classes in this 
testing. Our reviewer found the physician order does not include enough information to confirm a 22 or more 
drug class was ordered. Therefore, this procedure code cannot be verified. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the definitive drug testing as billed have not been met. Therefore, we decided 
that the Plan does not have to pay for the definitive drug testing provided on August 3, 2022, billed with code 
G0483.