Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Partially Favorable

 
We decided that the Plan has to pay for the services described by procedure code(s) 82607, 82747, 85025 and 
80053. We decided that the Plan does not have to pay for the services described by procedure code(s) 83550.  
 
You asked the Plan to pay for laboratory services provided on October 12, 2022. You say that these services 
were medically necessary and are supported in the medical record. The Plan says that payment for code 83550 
is bundled into payment for code 84466. 
 
We decided that the Plan has to pay for the services described by procedure code(s) 82607, 82747, 85025 
and 80053.  
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan did not make an appeal decision for the codes listed in this 
section. The Plan is not allowed to reopen any determinations while an appeal is pending and must issue a 
determination on all appealed services within the appeal time frame. As the Plan forfeited its opportunity to 
provide a denial rationale for these services, we find that the denial of payment is not supported. Therefore, we 
decided that the Plan has to pay for the services described by procedure code(s) 82607, 82747, 85025 and 
80053.  
 
We also decided that the Plan does not have to pay for the services described by procedure code(s) 
83550. 
 
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 83550 
is a column II code to column I code 84466 with a modifier indicator of 0. The column II code is therefore not 
payable. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that 
the Plan does not have to pay for the services described by procedure code(s) 83550. 
 
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 ViviGen. 
 
You asked the Plan to pre-approve ViviGen. You say that the records provided support the need for the 
services in dispute. The Plan denied your request. The Plan says published studies do not demonstrate any 
long-term health outcome advantage with the use of ViviGen as an alternative to standard bony allografts. 
 
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 ViviGen. Our reviewer says that 
ViviGen is not considered medically reasonable and necessary in this case. Our physician reviewer found there 
is limited published, large-scale, long-term peer-reviewed literature that shows this requested allograft 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. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of ViviGen have not been met. Therefore, we decided that the Plan does not have 
to pre-approve ViviGen.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel rendered on 
December 28, 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 urinalysis is the standard of care for a urinary tract 
infection (UTI). 
 
We looked at the file and Medicare rules. The file shows that the services at issue exceeded the standard of care 
for the diagnosis and treatment of a UTI. 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 
urine polymerase chain reaction (PCR) panel rendered on December 28, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Minuteman G3-R Intraspinous fixation device 
(22840). 
 
You asked the Plan to pre-approve the Minuteman G3-R Intraspinous fixation device (22840). You say that the 
requested Minuteman G3-R Intraspinous fixation device (22840) is medically necessary. The Plan denied your 
request. The Plan says the requested Minuteman G3-R Intraspinous fixation device (22840) 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 Minuteman G3-R Intraspinous fixation device (22840). Our reviewer says that the requested Minuteman G3-R Intraspinous fixation device 
(22840) is not medically necessary. Our physician reviewer found the Minuteman device is experimental. More 
research is needed 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 Minuteman G3-R Intraspinous fixation device (22840) have not been met. 
Therefore, we decided that the Plan does not have to pre-approve the Minuteman G3-R Intraspinous fixation 
device (22840).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the laryngoscopy performed on December 
8, 2022. 
 
You asked the Plan to waive the copayment for the laryngoscopy. You say that you do not agree with the 
copayment. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay a $475 
copayment for each Medicare-covered outpatient hospital facility visit. 
 
You have been asked to pay a $202.69 copayment for the laryngoscopy because the allowed amount for this 
service is less than the $475 copayment. This item/service falls within the 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 waive the copayment for the laryngoscopy performed on December 8, 2022.
Appeal type: Lab
Decision: Partially Favorable

 
We decided that the Plan has to pay for procedure codes 95885, 95927 and 95907. We decided that the Plan 
does not have to pay for procedure code 95955.  

You asked the Plan to pay for procedure codes 95955, 95885, 95927 and 95907 billed for date of service June 
18, 2021. You say that these services were necessary and are supported as billed. The Plan says that these 
services are not supported in the medical record. 
 
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 decided that the Plan has to pay for procedure codes 95885, 95927 and 95907.  
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for procedure codes 95885, 95927 and 95907. Our reviewer says 
that these codes are supported in the medical record. Our physician reviewer found that the documentation 
includes evidence that these exams were performed, and the results were included in the provided records.  
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 95885, 95927 and 95907 have been met. Therefore, we 
decided that the Plan has to pay for procedure codes 95885, 95927 and 95907.  
 
We also decided that the Plan does not have to pay for procedure code 95955. 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for procedure code 95955. Our reviewer says that this code is 
not supported in the medical record. Our physician reviewer found that the documentation shows that the 
electroencephalogram (EEG) was not performed during cardiac surgery. Therefore, there is a more appropriate 
code which would be more accurate with the operative report.  
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 95955 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 95955. 
 
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 robot-assisted surgical navigation services. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says medical 
studies have not proven this technique helpful. 
 
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 services. Our physician 
reviewer found that the enrollee is being treated for primary osteoarthritis of the left shoulder. The health plan 
has approved an elective left total shoulder arthroplasty with 2-day inpatient stay.  

However, there are no large volume, long-term/high-quality clinical studies that confirm the clinical benefits (ultimate outcomes of functional improvement and pain reduction) of computer-assisted surgery over standard surgical approaches in total shoulder arthroplasty. No compelling rationale is presented, or extenuating circumstances noted to support the medical necessity of this request as an exception. Therefore, the requested robot-assisted surgical navigation, 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 services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve robot-assisted surgical navigation services.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pay for procedure code J1170KD provided on September 9, 2022. 
 
You asked the Plan to pay for procedure code J1170KD. You say that you would like the Plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says that the services are not covered as billed. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. In this case, we find that the Plan has not provided enough evidence to support 
the denial of payment for procedure code J1170 based on Medicare criteria. The Local Coverage Determination 
(LCD) that the Plan based their denial on does not specifically say that procedure code J1170 is not payable if 
the KD modifier is appended. We find that the Plan has not substantiated their reasoning for the denial. 
Therefore, we decided that the Plan has to pay for procedure code J1170KD provided on September 9, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable controller (E2377), harness (E2313) and 
electronic connection (E2311). 
 
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. 
 
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 adequate strength to manage standard power drives on a wheelchair. Medical necessity 
criteria not met as the request exceeds 
 
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 an expandable controller (E2377), harness (E2313) and electronic connection (E2311).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code J2000 billed for date of service October 18, 2022. 
 
You asked the Plan to pay for code J2000. You say that the codes on this claim were denied incorrectly. The 
Plan denied your request. The Plan says code J2000 is not a valid code.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. In this 
case, the CPT Code Manual shows that code J2000 was discontinued in 2004 and no replacement code was 
assigned.  This code is no longer valid. Therefore, we decided that the Plan does not have to pay for code J2000 
billed for date of service October 18, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the bone replacement grafts on tooth #22 and 27 
(D4263). 
 
You asked the Plan to pre-approve the bone replacement grafts. You say that the requested services are 
medically necessary. The Plan denied your request. The Plan says that bone replacement grafts (D4263) are not 
covered by the enrollee's dental benefits. 
 
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 pre-approve the 
bone replacement grafts on tooth #22 and 27 (D4263).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator. 
 
You asked the Plan to pre-approve a ventilator. 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. 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 a ventilator. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found a home ventilator is not medically necessary. If this enrollee does have chronic carbon dioxide (CO2) retention, may benefit from bilevel positive 
airway pressure (BiPAP) during sleep as an outpatient. Medicare does not cover a home ventilator when used 
at settings that can be provided with BiPAP. 
 
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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve the OON office visit. You did not provide a specific argument with your 
appeal request. The Plan denied your request. The Plan says care is available from in-network providers. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
an office visit to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home infusion therapy services requested with 
procedure code S9328. 
 
You asked the Plan to pre-approve procedure code S9328. You did not provide a specific argument for 
coverage with your appeal request. The Plan denied your request. The Plan says the requested code is invalid 
for Medicare purposes. The Plan has approved the requested Baclofen, but the actual infusion therapy code 
submitted by the provider is not correct for Medicare purposes. 
 
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 S9328 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of procedure code S9328 have not been met. Therefore, we decided that the Plan does not 
have to pre-approve home infusion therapy services requested with procedure code S9328.  
 
Please note that you may contact your provider to ask them to submit a request for home infusion services with 
an appropriate code.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator. 
 
You asked the Plan to pre-approve a ventilator. 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. 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 a ventilator. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the record indicates that you were successfully treated with bilevel positive airway pressure (BiPAP). The provided primary source 
documentation does not contain sufficient detailed information in the medical record to justify the treatment 
selected. You could be treated with a BiPAP machine with average volume-assured pressure support (AVAPS) 
capability and failure of such a device has not been documented. The plan has indicated coverage for such a 
device is available upon request. The elements of the coverage criteria are not satisfied. The requested service 
cannot be recommended. 
 
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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the DyAnsys Drug Relief device. 
 
You asked the Plan to pre-approve the DyAnsys Drug Relief device.. You say that this device should not be 
considered investigational.  The patient would be an excellent candidate for this device to help with chronic 
pain and to reduce the use of narcotics. The Plan denied your request. The Plan says this device is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that electro-acupuncture devices are non-covered. 
The DyAnsys Drug Relief device is clearly an electro-acupuncture device.  The manufacturer's own website 
describes this item by stating that "stimulation is performed by sending electrical pulses emitted through 
needles strategically positioned in the ear. The ear provides numerous points for stimulation within a small 
area."  This is precisely what electro-acupuncture is, and it is therefore not covered under Medicare rules. 
Therefore, we decided that the Plan does not have to pre-approve the DyAnsys Drug Relief device.