Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve endoskeletal knee-shin system, single axis, fluid swing 
and stance phase control (L5828), an endoskeletal, knee-shin system, stance flexion feature (L5845), a fluid 
stance extension (L5848), an endoskeletal knee-shin system, microprocessor control feature (L5856) and an 
ankle foot system, microprocessor-controlled feature (L5973). 
 
You asked the Plan to pre-approve an advanced foot feature, an electronic knee and other parts. You say that he 
cannot walk on crutches or any kind of device. He does not agree with our decision. He has tried the 
unit and did benefit from this. The Plan denied your request. The Plan says the request for integrated 
microprocessor knee and foot system does not meet Medicare criteria as reasonable and 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 an advanced foot feature, an electronic 
knee and other parts. Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found you have a history of six knee 
replacements, eleven revisions, a stroke, heart disease and disorder of lumbosacral intervertebral disc. You 
have right arm numbness and neck pain and received spine injections from pain management. L5828, L5845, 
L5848, L5856, and L5973 (advanced foot and electronic knee system) are not medically necessary per LCD 
L33787, as Medicare does not pay for any items or services that are not reasonable and necessary for the 
diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member. The 
documentation does not support that you are a K3 ambulator. The physician medical progress notes do not 
support that you require a heavier microprocessor knee and ankle over a mechanical knee and ankle. The Linx 
system has deluxe features that exceed your medical and functional needs. They are not medically necessary 
such as a sandal toe foot shell and cosmetic cover. 
 
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 advanced foot feature, an electronic knee and other parts have not been met. 
Therefore, we decided that the Plan does not have to pre-approve endoskeletal knee-shin system, single axis, 
fluid swing and stance phase control (L5828), an endoskeletal, knee-shin system, stance flexion feature 
(L5845), a fluid stance extension (L5848), an endoskeletal knee-shin system, microprocessor control feature 
(L5856) and an ankle foot system, microprocessor-controlled feature (L5973).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Medtronic Mastergraft allograft, represented by CPT 
code(s) 20930. 
 
You asked the Plan to pre-approve Medtronic Mastergraft allograft, represented by CPT code(s) 20930. You 
say that you disagree with the Plan's denial. The Plan denied your request. The Plan says the requested 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 Medtronic Mastergraft allograft, 
represented by CPT code(s) 20930. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee was being treated 
for low back pain and spinal stenosis of the lumbar region with neurogenic claudication, neurogenic 
claudication due to lumbar spinal stenosis, and spondylolisthesis of the lumbar region. The enrollee presented 
with two years of progressive low back pain and bilateral leg symptomatology. The exam reveals focal 
tenderness to palpation at the L2-3 and L3-4 facet joints and does not tolerate facet loading signs. Strength and 
sensation are intact. However, 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. Therefore, the requested Medtronic Mastergraft allograft 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 Medtronic Mastergraft allograft, represented by CPT code(s) 20930 have not 
been met. Therefore, we decided that the Plan does not have to pre-approve Medtronic Mastergraft allograft, 
represented by CPT code(s) 20930.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental services identified with codes D2950 and D2740. 
 
You asked the Plan to pre-approve dental services identified with codes D2950 and D2740. You say that you 
disagree with the Plan's denial. The Plan denied your request. The Plan says the requested services are 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 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 
dental services identified with codes D2950 and D2740.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a prosthetic leg with an advanced foot feature (L5968,
L5981).
You asked the Plan to pre-approve these items. You say that these items are medically necessary. The Plan
denied your request. The Plan says that based on the documentation provided, coverage criteria has not been
met.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for a prosthetic leg
with an advanced foot feature (L5968, L5981). Our Medical Director states that the clinical documentation is
insufficient to demonstrate that the enrollee in this case has a functional level of 3 or above. Our physician
reviewer found that the enrollee's condition does not meet criteria for coverage of these items.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of these items have not been met. Therefore, we decided that the Plan does not
have to pre-approve a prosthetic leg with an advanced foot feature (L5968, L5981).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the office visits and drug injection provided 
from August 24, 2022, to September 29, 2022. 
 
You asked the Plan to waive the cost share for the office visits and drug injection. You say that you already 
paid your copayments for these services. 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 $45 
copayment for in-network specialist physician/practitioner services. Your contract with the Plan also clearly 
says that you must pay 20% coinsurance for in-network Medicare Part B drugs. 
 
You have been asked to pay a $45 copayment for each specialist office visit. This item/service falls within the 
physician/practitioner services benefit category. You have also been asked to pay $2.06, which is 20% 
coinsurance of the allowed amount for the drug injection provided on August 24, 2022 ($10.32 allowed amount 
x 20% coinsurance = $2.06). 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 cost share for the office visits and drug 
injection provided from August 24, 2022, to September 29, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87652 billed for date of service February 1, 
2023.  
 
You asked the Plan to pay for procedure code 87652. You say that this testing was medically necessary and 
was reported appropriately. The Plan denied your request. The Plan says this service is 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. In this case, the CPT Code Manual definition of 
code 87652 is infectious agent detection by nucleic acid (DNA or RNA); Streptococcus, group A, 
quantification. 

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 87652. Our reviewer says that this code is 
not supported in the medical record. Our reviewer found the laboratory report does not include "quantification" 
for this test. Therefore, this procedure 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 procedure code 87652 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 87652 billed for date of service February 1, 2023.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the doppler echocardiography (93320 and 93325) provided on March 
21, 2023. 
 
You asked the Plan to pay for the doppler echocardiography (93320 and 93325). You say that the medical 
records support procedure codes 93312, 93320 and 93325. You say that these are separately payable codes, and 
the claim should be reprocessed to pay these codes. The Plan denied your request. The Plan says that procedure 
codes 93320 and 93325 were not billed with an appropriate primary code that is eligible for payment. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare rules say that providers must report 
services correctly. Providers must report services with the appropriate CPT code. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the doppler echocardiography (93320 and 93325) have been met. Specifically, both add-on codes 
were billed with procedure code 99312, which is an appropriate primary procedure code that the Plan 
determined is eligible for payment. Therefore, we decided that the Plan has to pay for the doppler 
echocardiography (93320 and 93325) provided on March 21, 2023.  
 
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 a left and right armrest (E0973), a power seat elevation
system (E2300), an expandable controller (E2377), an expandable controller harness (E2313), an electronic
connection (E2311), pull up foot straps and accessory bar for push down footplates (K0108) for the enrollee.
You asked the Plan to pre-approve these items. You say that these items are medically necessary. The Plan
denied your request. The Plan says that these items are not medically necessary.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for an expandable
controller, harness, electronic connection and pull up foot straps and accessory bar for push down footplates.
Our Medical Director states that the documentation does not support that the enrollee had a covered indication
for the requested expandable controller, expandable controller harness, and electronic connection to control
power tilt, recline and power elevating leg rests through the joystick and that the requested features were
medically reasonable and necessary for the enrollee in this case. The pull up foot straps and accessory bar for
push down footplates are primarily convenience in nature, especially since the power seat elevator is not
medically necessary and not considered medical in nature. Our physician reviewer found that the enrollee's
condition does not meet criteria for coverage of an expandable controller, harness, electronic connection and
pull up foot straps and accessory bar for push down footplates.
Medicare rules say a Column II code is included in the allowance for the corresponding Column I code
when provided at the same time. When multiple codes are listed in column I, all the codes in column II relate to
each code in column I. In this case, code E0973 is listed under Column II, and code E1007 is listed under
Column I. Therefore, payment of E0973 is included in the approved E1007 code and should not be requested
separately.
Lastly, Medicare rules say a power seat elevation system (E2300) is statutorily non-covered 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 these items have not been met. Therefore, we decided that the Plan does not
have to pre-approve a left and right armrest (E0973), a power seat elevation system (E2300), an expandable
controller (E2377), an expandable controller harness (E2313), an electronic connection (E2311), pull up foot
straps and accessory bar for push down footplates (K0108) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service March 1, 
2023. 
 
You asked the Plan to pay for procedure code 99100. You say that this service should be covered under the 
surgeon's authorization. The Plan denied your request. The Plan says procedure code 99100 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 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service March 1, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) of the sacroiliac (SI) 
joint nerves. 
 
You asked the Plan to pre-approve the RFA procedure. You say that this treatment should be allowed.  The 
Plan denied your request. The Plan says there is insufficient evidence to show safety/efficacy of this procedure.  
 
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 procedure. Our reviewer says 
that the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found this treatment is considered experimental/investigational because of the wide variation in 
efficacy reported in the literature. Therefore, the request is deemed not medically reasonable and necessary. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the RFA procedure have not been met. Therefore, we decided that the Plan does 
not have to pre-approve radiofrequency ablation (RFA) of the sacroiliac (SI) joint nerves.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a genicular nerve branch injection. 
 
You asked the Plan to pre-approve a genicular nerve branch injection. You say that a genicular nerve branch 
injection is medically necessary. The Plan denied your request. The Plan says a genicular nerve branch 
injection 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 a genicular nerve branch injection. Our 
reviewer says that the requested genicular nerve branch injection is not considered medically reasonable and 
necessary. Our physician reviewer found that this is considered an experimental/investigational procedure and 
is the subject of ongoing clinical trials. Therefore, the request is deemed not medically reasonable and 
necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a genicular nerve branch injection have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a genicular nerve branch injection.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee is progressing towards goals and would 
benefit from further therapy. The Plan denied your request. The Plan says the enrollee does not meet criteria for 
approval. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee was admitted for myasthenia gravis. Medical problems are stable. There 
are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, 
including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. 
While the medical record supports a need for physical and/or occupational therapy, there is no documented 
need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. 
There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the 
intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home sleep test device. 
 
You asked the Plan to pre-approve a home sleep test device. 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 sleep tests are covered when specific criteria 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 a home sleep test device. Our reviewer 
says that the services are not medically necessary. Our physician reviewer found the enrollee previously had a 
sleep study performed on April 25, 2022, which showed moderate sleep apnea and an apnea-hypopnea index 
(AHI) of 13.9. The enrollee was prescribed continuous positive airway pressure (CPAP) as a result. The 
enrollee's request is to have another sleep study to assess qualification for Inspire procedure. 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 home sleep test device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a home sleep test device.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve nerve ablation. 
 
You asked the Plan to pre-approve nerve ablation. You say that this procedure is medically necessary for this 
enrollee. The Plan denied your request. The Plan says that the procedure is considered experimental and 
investigational. 
 
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 nerve ablation. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that this procedure is still considered experimental and investigational. 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of nerve ablation have not been met. Therefore, we decided that the Plan does not 
have to pre-approve nerve ablation.