Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99072 billed for date of service July 23, 
2022. 
 
You asked the Plan to pay for procedure code 99072. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says procedure code 99072 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 99072 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99072 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99072 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99072 billed for date of service July 23, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87500 billed for date of service May 20, 
2022. 
 You asked the Plan to pay for procedure code 87500. You say that you disagree with the denial. 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 87500 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 87500 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 87500 billed for date of service May 20, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient hospital care. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that the enrollee was approved for an 
endoscopic cricopharyngeal myotomy and will need inpatient admission after surgery. The Plan denied your 
request. The Plan says there is no documentation provided to support the expectation the enrollee will require a 
greater than 2 midnight stay. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.   
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 acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient admission are met in this 
case. Our physician reviewer found the enrollee is approved for an endoscopic cricopharyngeal myotomy. The 
record does not document that the treating physician has a reasonable expectation of a length of stay spanning 2 
or more midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve acute inpatient hospital care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the disposable drug delivery system, flow rate of 50 ml or 
greater per hour (A4305) provided October 27, 2021, to November 1, 2021. 
 You asked the Plan to pay for the disposable drug delivery system. You say that please process the claim for 
payment. The Plan denied your request. The Plan says this service is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. The Medicare rules specifically says that drugs and supplies used 
with disposable drug delivery systems are also non-covered items. Based on this information, we decided that 
Medicare rules for coverage of the disposable drug delivery system have not been met. Therefore, we decided 
that the Plan does not have to pay for the disposable drug delivery system, flow rate of 50 ml or greater per 
hour (A4305) provided October 27, 2021, to November 1, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the immunoglobulin light chains (ie, kappa, lambda), free, 
each (83521) provided January 4, 2022. 
 
You asked the Plan to pay for the laboratory service. You say that the provider's staff says there has been a 
change in the code number for the procedure your doctor believes is necessary to keep up with your health 
condition. The Plan denied your request. The Plan says this code has been considered experimental, 
investigational and uproven for all diagnoses and for all Plans. 
 The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the laboratory service have not been met. Therefore, we decided that the Plan does not have to pay 
for the immunoglobulin light chains (ie, kappa, lambda), free, each (83521) provided January 4, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the electronic connection (E2310) to allow control of 
power tilt from the main drive control. 
 
You asked the Plan to pre-approve the electronic connection. You say that it is felt that all requested 
components should be approved. The Plan denied your request. The Plan says all items were approved aside 
from the electronic connection. 
 
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 electronic connection. Our reviewer 
says that the documentation does not support that control of the power tilt seating system from the main drive 
control is considered medically reasonable and necessary in this case. Our physician reviewer found the 
provided records document that the enrollee has 5/5 bilateral wrist extension and 0/5 finger flexion and is independent with grooming and independent with eating. This indicates he has adequate upper extremity 
strength and function to operate the wheelchair's power options with their own switches.  
 
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 electronic connection have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the electronic connection (E2310) to allow control of power tilt from the 
main drive control.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the bone marrow aspirate (CPT code 20939). 
 
You asked the Plan to pre-approve the bone marrow aspirate. You say that the service is medically necessary. 
The Plan denied your request. The Plan says the clinical value and effectiveness of bone marrow aspirate in the 
setting of spinal fusion surgery 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 bone marrow aspirate. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found bne marrow aspirate remains experimental 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 bone marrow aspirate have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the bone marrow aspirate (CPT code 20939).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve unoccupied tiedown supplies (K0108) for a power 
wheelchair. 
 
You asked the Plan to pre-approve unoccupied tiedown supplies. You say that the requested supplies are a 
medical necessity for you. The Plan denied your request. The Plan says rules for coverage for durable medical 
equipment have not been met. 
 
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. Therefore, we decided that the Plan does not have to pre-approve unoccupied tiedown supplies (K0108) for a power 
wheelchair.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code A4557 billed for date of service April 13, 
2022. 
 
You asked the Plan to pay for procedure code A4557. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
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 code A4557 has a status code of "P" under the Medicare Physicians Fee Schedule Database 
(MPFSDB) and no separate payment is made for this code under the fee schedule as payment is bundled into 
the payment for the services to which these codes are incident to. Therefore, we decided that the Plan does not 
have to pay for procedure code A4557 billed for date of service April 13, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the cataract surgery provided on July 5, 
2022. 
 
You asked the Plan to reduce the copayment for the cataract surgery. You say that you were told your 
copayment would be $276 and that the cataract surgery was approved. 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 $325 
copayment for each Medicare-covered outpatient surgery at an outpatient hospital facility. 
 
You have been asked to pay a $325 copayment for the cataract surgery. This item/service falls within 
outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 
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 reduce the copayment for the cataract surgery and the 
posterior chamber intraocular lens provided on July 5, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve allograft services using Medtronic Fibercel. 
 
You asked the Plan to pre-approve the requested allograft services. You say that this procedure is medically 
necessary for the enrollee's condition. The Plan denied your request. The Plan says the necessity of the 
requested services have not been established after clinical review and per the peer-reviewed medical 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 requested allograft services. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found that this 69-year-old female was being treated for spondylolisthesis of the 
lumbar region. She presented with back pain and right leg discomfort. The right leg is the majority of the pain 
and the pain exists from her buttocks down the lateral aspect of the entire leg. The exam reveals a full range of motion. Straight leg raise is positive on her right. The Plan has approved the L3-4 and L4-5 lateral 360 fusion 
with posterior spinal fusion and laminectomies. 
 
In this case, there is limited published, large-scale, long-term peer-reviewed literature that shows DBF 
(demineralized bone fibers) to be an effective and/or safe treatment for the noted pathology. Further studies are 
needed to demonstrate this request has beneficial outcomes compared with conventional treatment. There is no 
compelling rationale presented or extenuating circumstances noted to support the medical necessity of this 
request as an exception. Therefore, the requested allograft using Medtronic Fibercel, 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 the requested allograft services have not been met. Therefore, we decided that 
the Plan does not have to pre-approve allograft services using Medtronic Fibercel.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional physical therapy provided by a participating 
provider. 
 
You asked the Plan to pre-approve physical therapy. You say that you need additional physical therapy. The 
Plan denied your request. The Plan says the requested physical therapy sessions are not medically necessary. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 physical therapy. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found the requested services are not part of a maintenance program, and the 
specialized skill, knowledge and judgment of a qualified therapist is not required to establish, design and/or 
deliver a program to maintain the enrollee's current condition or to prevent or slow further deterioration. The 
enrollee can transition to an independent home exercise program. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of physical therapy have not been met. Therefore, we decided that the Plan does 
not have to pre-approve additional physical therapy provided by a participating provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hotel aid services rendered from April 25, 2022, to May 
17, 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 the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare generally does not cover items and services 
furnished outside of the United States and custodial care is not covered. 
 
We looked at the file and Medicare rules. The services at issue are hotel aide services received while outside of 
the United States. These services are custodial in nature and are not covered. Therefore, we decided that the 
Plan does not have to pay for the hotel aid services rendered from April 25, 2022, to May 17, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an adjunctive pre-diagnostic test (D0431) provided on July 
28, 2022. 
 
You asked the Plan to pay for an adjunctive pre-diagnostic test. You say that you were shocked to get a bill this 
high. The Plan denied your request. The Plan says the rendered dental work is not a covered benefit. 
 
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 an 
adjunctive pre-diagnostic test (D0431) provided on July 28, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connection for controls (E2311). 
 
You asked the Plan to pre-approve an electronic connection for controls. You say that this is medically 
necessary. The Plan denied your request. The Plan says the enrollee can control the power options with their 
own switches. 
 
The Plan follows Medicare rules. Medicare rules say that code E2311 describes the electronic components that 
allow the beneficiary to control two or more of the following motors from a single interface. 
 
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 electronic connection for controls. 
Our reviewer says that the requested item is not medically necessary. Our physician reviewer found the enrollee has adequate upper extremity strength and function to operate the wheelchair's power options with 
their own switches. 
 
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 electronic connection for controls have not been met. Therefore, we decided 
that the Plan does not have to pre-approve an electronic connection for controls (E2311).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the third facet joint injection (CPT code 64495). 
 
You asked the Plan to pre-approve the injection. You say that the injection is necessary. The Plan denied your 
request. The Plan says more than two (2) levels is only considered medically necessary under unique 
circumstances and with sufficient documentation of medical necessity on appeal. The Plan states the enrollee's 
case does not provide sufficient documentation of unique circumstances. 
 
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 injection. Our physician reviewer 
found the request for a third level exceeds utilization criteria and therefore, the request is deemed not medically 
reasonable and necessary. There were no exceptional circumstances detailed. 
 
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 injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the third facet joint injection (CPT code 64495).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88342 billed for date of service June 3, 2022. 
 
You asked the Plan to pay for procedure code 88342. You say that the service at issue has been billed correctly. 
The Plan denied your request. The Plan says this claim is a duplicate of a previously paid claim and was 
correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on July 26, 2022. Comparison of the two claims shows these are exact duplicates. There 
is no evidence presented to support that the billed items/services were provided twice on the same date. Based 
on this information, we decided that the Medicare rules for procedure code 88342 have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure code 88342 billed for date of service 
June 3, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on June 23, 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 code 87500 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 87500 is infectious agent detection by nucleic acid (DNA 
or RNA); vancomycin resistance (eg, enterococcus species van A, van B), amplified probe technique. 
 
We find that CPT code 87500 is not supported in the medical record. Specifically, there is no documentation of 
infectious agent detection by nucleic acid for vancomycin resistance, amplified probe technique. 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 laboratory services rendered on June 23, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 94761, 95921 and 95923 billed for date of 
service October 21, 2021. 
 
You asked the Plan to pay for procedure codes 94761, 95921 and 95923. You say that the services at issue 
were a necessity for the enrollee's care. The Plan denied your request. The Plan says rules for payment have not 
been met. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. Medicare rules also say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of procedure codes 95921 and 95923 
have been met. Specifically, no medical records were provided to support the medical necessity of the services 
indicated by procedure codes 95921 and 95923. We find that procedure code 94761 has a status indicator of T 
on the Physician Fee Schedule. This means that procedure code 94761 is not separately payable. Based on this 
information, we decided that Medicare rules for coverage of procedure code 94761 have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure codes 94761, 95921 and 95923 billed 
for date of service October 21, 2021.