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

 
We decided that the Plan does not have to pre-approve a high frequency chest wall oscillation (HFCWO) 
system. 
 
You asked the Plan to pre-approve a HFCWO system. 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 high frequency chest wall oscillation devices 
(HFCWO) (E0483) are covered for beneficiaries who meet specific 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 a HFCWO system. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found the review indicates that the 
enrollee has a history chronic obstructive pulmonary disease. The records show that she has a cough and 
difficulty coughing up mucus. A computed tomography (CT) scan shows pneumonia. Under Medicare 
guidelines, the requested item is not medically necessary because the records do not show that the enrollee has 
a diagnosis of cystic fibrosis, bronchiectasis, or neuromuscular disease. The review has determined that the 
enrollee does not meet the coverage criteria detailed in the NCD. 
 
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 HFCWO system have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a high frequency chest wall oscillation (HFCWO) system.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on October 5, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the dental services were received from an out-of-
network provider and are not covered by your supplemental benefits. 
 
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. 
 
The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for the dental services on October 5, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance service, basic life support, non-emergency 
transport provided on June 2, 2021. 
 
You asked the Plan to pay for the ambulance service, basic life support, non-emergency transport. You say that 
the claim was denied in error for timely filing. The Plan denied your request. The Plan says the claim was not 
received within the allowed 12 months from the date of service. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
 
 
 The record shows that a claim for the ambulance service, basic life support, non-emergency transport was not 
filed until August 16, 2022. This means that more than one calendar year from the date of service had passed 
before a claim was filed. Therefore, we decided that the Plan does not have to pay for ambulance service, basic 
life support, non-emergency transport provided on June 2, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 75571 billed for date of service October 5, 
2022. 
 
You asked the Plan to pay for procedure code 75571. You say that the enrollee had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 75571 is bundled into payment for 
code 75572. 
 
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 75571 is a column II code to column I code 75572. The code at issue 
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 
75571 billed for date of service October 5, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for core buildup (D2950). 
 
You asked the Plan to pay for core buildup (D2950). You say that you cannot chew on the side of your mouth 
where the false tooth has a part broken off in the back. You also say that every time you gloss, the teeth next to 
the bridge or under it, the bridge feels like it might come out. The Plan denied your request. The Plan says 
according to the 2023 EOC, there is no coverage for core buildup (D2950). 
 
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 pay for core 
buildup (D2950).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76705 billed for date of service October 15, 
2022. 
 
You asked the Plan to pay for procedure code 76705. You say that the services at issue have been billed 
correctly. The Plan denied your request. The Plan says payment for code 76705 is bundled into payment for 
code 93976. 
 
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 76705 
is a column II code to column I code 93976. 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 76705 billed for date of service October 15, 
2022.
Appeal type: Surgery
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve inpatient hospital care. We decided that the Plan does not have 
to pre-approve MAKOplasty (left side) (0055T-LT).  
 
You asked the Plan to pre-approve MAKOplasty (left side) (0055T-LT) and inpatient hospital care. You say 
that the services are necessary. The Plan says that the Plan does not cover the use of robotic or computer-
assisted surgical navigation for the enrollee's planned surgery. The Plan states medical studies have not proven 
the use of this technique is helpful with the enrollee's surgery. 
 
We decided that the Plan has to pre-approve inpatient hospital 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 the services. Our reviewer says that the 
enrollee has well documented significant past and/or current medical history that would place this enrollee at 
increased risk for peri-surgical complications requiring an inpatient stay. Therefore, the requested inpatient 
hospital care for the planned left knee arthroplasty, in this case, is 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 services have been met. Therefore, we decided that the Plan has to pre-
approve inpatient hospital care.  
 
We also decided that the Plan does not have to pre-approve MAKOplasty (left side) (0055T-LT). 
 
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 MAKOplasty (left side) (0055T-LT). 
Our reviewer says that there are no large volume, long term/high quality clinical studies that confirm clinical 
benefits (ultimate outcomes of functional improvement and pain reduction) of computer-assisted surgery over 
standard surgical approaches in total knee arthroplasty. There is no compelling rationale presented or 
extenuating circumstances noted to support the medical necessity of this request as an exception. Therefore, the 
requested robotic/computer-assisted surgical navigation for the planned left knee arthroplasty, in this case, is 
not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of MAKOplasty (left side) (0055T-LT) have not been met. Therefore, we decided 
that the Plan does not have to pre-approve MAKOplasty (left side) (0055T-LT). 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve drive wheels, shroud, and associated labor for a manual 
wheelchair.  

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 for equipment to be covered, it must primarily serve a 
medical purpose. The rules say that items that do not contribute meaningfully to the treatment of an illness or 
injury or the functioning of a malformed body member are not covered. The rules say that repairs to equipment 
are covered when necessary and not for an item under warranty.  
 
The requested shroud does not serve a purpose that is primarily medical in nature. The associated labor is not a 
service that contributes meaningfully to the treatment of an illness or injury. There is no documentation that the 
drive wheels are broken and need repair. Therefore, we decided that the Plan does not have to pre-approve 
drive wheels, shroud, and associated labor for a manual wheelchair.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services billed with codes 37229, 36247, 37252, 75716, 
37253, and 75625 for September 12, 2022. 
 
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 procedure codes 37229, 36247, 37252, 75716, 37253, and 75625 are 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 37229 is revascularization, endovascular, open or 
percutaneous, tibial, peroneal artery, unilateral, initial vessel; with atherectomy, includes angioplasty within the 
same vessel, when performed.  

The definition of code 36247 is selective catheter placement, arterial system; initial third order or more 
selective abdominal, pelvic, or lower extremity artery branch, within a vascular family. The definition of code 
37252 is intravascular ultrasound (noncoronary vessel) during diagnostic evaluation and/or therapeutic 
intervention, including radiological supervision and interpretation; initial noncoronary vessel (List separately in 
addition to code for primary procedure). The definition of code 75716 is angiography, extremity, bilateral, 
radiological supervision and interpretation. The definition of code 37253 is intravascular ultrasound 
(noncoronary vessel) during diagnostic evaluation and/or therapeutic intervention, including radiological 
supervision and interpretation; each additional noncoronary vessel (List separately in addition to code for 
primary procedure). The definition of code 75625 is aortography, abdominal, by serialography, radiological 
supervision and interpretation. 
 
We find that CPT codes 37229, 36247, 37252, 75716, 37253, and 75625 are not supported in the medical 
record. Specifically, there is no documentation of an open or percutaneous endovascular revascularization of a 
unilateral tibial or peroneal artery for the initial vessel with atherectomy to support code 37229. There is no 
documentation of selective catheter placement for the arterial system to support code 36247. There is no 
documentation of an intravascular ultrasound to support code 37252. There is no documentation of a bilateral 
extremity angiography with radiological supervision and interpretation to support code 75716. There is no 
documentation of intravascular ultrasound of a noncoronary vessel to support code 37253. There is no 
documentation of an abdominal aortography by serialography to support code 75625. 
 
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 services billed with codes 37229, 36247, 
37252, 75716, 37253, and 75625 for September 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nursing facility care provided on August 26, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for nursing facility care. You say that the records attached support the services 
provided. The Plan denied your request. The Plan says [Enter plan denial rationale, e.g. "...rules for SNF care 
have not been met."
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
 The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for nursing facility care provided on August 26, 2022, 
by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 27335 billed for date of service June 7, 2022. 
 
You asked the Plan to pay for procedure code 27335. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says payment for code 27335 is bundled into payment for code 27447. 
 
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 27335 
is a column II code to column I code 27447. While this code was billed with modifier -59, the medical records 
provided do not show that the service billed with the -59 modifier is a distinct procedural service. 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 27335 billed for date of service June 7, 2022.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 0376T billed for date of service December 17, 2020. 
 
You asked the Plan to pay for the billed services. You say that the denial logic does not make sense. The Plan 
denied your request. The Plan says that the procedure code is not covered. 
 
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. 
 
We looked at the file and the rules. The Local Coverage Article, A56647, for the billing and coding of micro-
invasive glaucoma surgery, is not binding in this case. The rule did not have Medicare Part B jurisdiction 
where the services were provided. The Plan offered no other denial rationale for this case. The Plan has not 
made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny 
your request. Therefore, we decided that the Plan has to pay for procedure code 0376T billed for date of service 
December 17, 2020.  
 
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 pay for facet joint injections at 3 levels provided on \ 
August 25, 2022. 
 
You asked the Plan to pay for facet joint injections at 3 levels. You say that facet joint injections at 3 levels is 
medically necessary. The Plan denied your request. The Plan says one to two levels, either unilateral or 
bilateral, are allowed per session per spine region. The provider did not provide evidence of unique 
circumstances for a third level with sufficient documentation of medical necessity. 
 
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 pay for facet joint injections at 3 levels. Our 
reviewer says that facet joint injections at 3 levels is not medically necessary. Our physician reviewer found 
that the Medicare LCD limits utilization to 2 levels per session. There is no extraordinary circumstance 
described in the notes. Therefore, the additional levels are 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 facet joint injections at 3 levels have not been met. Therefore, we decided that 
the Plan does not have to pay for facet joint injections at 3 levels provided on August 25, 2022.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for procedure code 20526 billed for date of service April 15, 
2021. 
 
You asked the Plan to pay for procedure code 20526. You say that you disagree with the denial. The Plan 
denied your request. The Plan says payment for code 20526 is bundled into payment for code 20550. 
 
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 20526 
is a column II code to column I code 20550. 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 20526 billed for date of service April 15, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 37248-RT and 75820-26-59 billed for date 
of service August 23, 2022. 
 
You asked the Plan to pay for the billed services. You say that the enrollee had multiple exams on this date of 
service. The Plan denied your request. The Plan says the rules for payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
In this case, the CPT Code Manual definition of code 37248-RT is transluminal balloon angioplasty (except 
dialysis circuit), open or percutaneous, including all imaging and radiological supervision and interpretation 
necessary to perform the angioplasty within the same vein; initial vein. We find that CPT code 37248-RT is not 
supported in the medical record.  
 
The rules state that providers may bill services with a -59 modifier if the service billed with the modifier 
indicates a distinct procedural service.  The medical records provided do not show that 75820 billed with the -
59 modifier is a distinct procedural service. Based on this information, we decided that Medicare rules for 
coverage of the billed services have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure codes 37248-RT and 75820-26-59 billed for date of service August 23, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable controller and harness upgrade, 
electronic connection, and flip over half tray hardware. 
 
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 for equipment to be covered, it must primarily serve a 
medical purpose. Medicare rules say that an expandable controller is used to control multiple power options. 
 
The requested flip over half tray hardware does not serve a purpose that is primarily medical in nature. The file 
shows that the expandable controller and harness upgrades are not needed to control the approved power 
switches. 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 pre-approve an expandable controller and 
harness upgrade, electronic connection, and flip over half tray hardware.