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

 
We decided that the Plan does not have to pre-approve kyphoplasty (22513). 
 
You asked the Plan to pre-approve kyphoplasty. You say that this is medically necessary. The Plan denied your 
request. The Plan says you do not meet criteria. The documentation notes moderate foraminal stenosis. 
 
The Plan follows Medicare rules. Medicare rules say that kyphoplasty can be 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 kyphoplasty. Our reviewer says that 
you do not meet coverage criteria. Our physician reviewer found detailed documentation is not evident 
regarding worsening pain. There is no indication of a progression of the body height loss, greater than 25% 
vertebral body height loss, kyphotic deformity, or a severe impact on your daily activities. Moreover, there is 
magnetic resonance imaging corroboration of retropulsion. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of kyphoplasty have not been met. Therefore, we decided that the Plan does not 
have to pre-approve kyphoplasty (22513).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87491, 87529, 87625, 87591 and 87661 
billed for date of service February 21, 2023. 
 
You asked the Plan to pay for procedure codes 87491, 87529, 87625, 87591 and 87661. You say that you have 
billed the services at issue correctly. 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 providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT codes 87491, 87529, 87625, 87591 and 87661 are not supported in the medical record. 
Specifically, the provided medical records do not indicate that testing was performed for Chlamydia 
trachomatis (87491), Herpes simplex (87529), Human Papillomavirus (87625), Neisseria gonorrhoeae (87591) 
or Trichomonas vaginalis (87661). Based on this information, we decided that Medicare rules for coverage of 
procedure codes 87491, 87529, 87625, 87591 and 87661 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure codes 87491, 87529, 87625, 87591 and 87661 billed for date of service 
February 21, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Dexcom G6 transmitter.

You asked the Plan to pre-approve a Dexcom G6 transmitter. You say that the Dexcom G6 transmitter is
medically necessary. The Plan denied your request. The Plan says you do not meet criteria for a continuous
glucose monitor (CGM) system.

The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and
necessary for enrollees with diabetes who meet the criteria referenced 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 a Dexcom G6 transmitter. Our reviewer
says that the request doe not meet criteria. Our physician reviewer found the enrollee is not having low blood
sugars, although we are told the enrollee is on a medication, glimepiride, that can cause low blood sugars. The
enrollee is not using insulin and we are not told why fingerstick monitor would not suffice for his needs.
Therefore, criteria for a continuous glucose monitor coverage are not met.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of a Dexcom G6 transmitter have not been met. Therefore, we decided that the
Plan does not have to pre-approve a Dexcom G6 transmitter.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 95822 billed for April 27, 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 95822 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 95822 is electroencephalogram (EEG); recording in coma 
or sleep only. 
 
We find that CPT code 95822 is not supported in the medical record. Specifically, the records show that an 
intraoperative EEG was performed and there is a more appropriate code for the services. 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 procedure code 95822 billed for April 27, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87150, 87481, 87641, and 87653 billed for 
date of service December 30, 2022. 
 
You asked the Plan to pay for procedure codes 87150, 87481, 87641, and 87653. You say that you disagree 
with the Plan's denial. The Plan denied your request. The Plan says payment for codes 87150 is bundled into 
payment for other codes. 
 
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 87150 
is a column II code to column I code 87500. We have confirmed that codes 87481, 87641, and 87653 are 
column II codes to column I code 87801. 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 codes 87150, 87481, 87641, and 87653 billed for date of service 
December 30, 2022.
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 January 9, 
2023 to January 10, 2023. 
 
You asked the Plan to pay for procedure code 99100. You say that you disagree with the denial. 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. 
 
The rules say that intraoperative services are included in the global surgical package. The file shows that 
procedure code 99223 was billed on the same day as major surgical procedure 33025. Payment for code 99223 
is included in the global surgical package for 33025. 
 
Therefore, we decided that the Plan does not have to pay for procedure code 99100 billed for date of service 
January 9, 2023 to January 10, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 87631 for date of service January 4, 2023. 
 
You asked the Plan to pay for code 87631. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the claim for this molecular pathology testing did not include the required unique 
identifier. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of code 87631 have not 
been met. Therefore, we decided that the Plan does not have to pay for code 87631 for date of service January 
4, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for a metal post in jaw (D6010 x2), Alveoloplasty, w/o extractions, one to three teeth per quadrant (D7321 x2), and Material to help gums grow (D4266 x2).

You asked the Plan to provide coverage for these services. You say that these dental services should be covered by the Plan.  The Plan denied your request. The Plan says the services denied are not covered under the Plan benefit.  

The Plan is correct in this case. The benefit limit for D6010 was exhausted on April 17, 2023. Codes D7321 and D4266 are not covered dental benefits. Therefore, we decided that the Plan does not have provide coverage for these dental services. Again, we note the bone graft stated the to be approved by Maximus in the previous decision was already approved by the Plan and did not need review.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 97014 billed for date of service November 4, 
2022, to December 15, 2022. 
 
You asked the Plan to pay for procedure code 97014. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the billed code is invalid 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 97014 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code 97014 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code 97014 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 97014 billed for date of service November 4, 2022, to December 15, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve posterior segmental instrumentation (22842). 
 
You asked the Plan to pre-approve posterior segmental instrumentation. You say that this is medically 
necessary. The Plan denied your request. The Plan says this 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 posterior segmental instrumentation. 
Our reviewer says that the requested items/services are 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 request to be an effective and/or safe treatment for the noted pathology. Further 
studies are needed to demonstrate Stabilink is as good or better than standard treatments. No compelling 
rationale is 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 posterior segmental instrumentation have not been met. Therefore, we decided 
that the Plan does not have to pre-approve posterior segmental instrumentation (22842).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator for 9 months (E0466). 
 
You asked the Plan to pre-approve a ventilator for 9 months. 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 for 9 months. Our reviewer 
says that the services are not medically necessary. Our physician reviewer found the provided primary source 
documentation does not contain sufficient detailed information in the medical record to justify the treatment 
selected. The enrollee could be treated with a bilevel positive airway pressure (BiPAP) machine with average 
volume assured pressure support (AVAPS) capability and failure of such a device has not been 
documented. 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 for 9 months have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a ventilator for 9 months (E0466).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided the Plan does not have to provide coverage for long term acute care hospital (LTACH) services for
the enrollee.
You asked the Plan to provide coverage for the LTACH services. You say that LTACH services are medically
necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 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 LTACH services. Our reviewer says that the requested
LTACH care is not considered medically reasonable and necessary in this case.
Our physician reviewer found in this case the enrollee was admitted for elective esophageal stricture that was
complicated by septic shock from aspiration pneumonia. The record indicates that the enrollee is improving but
still requires acute care services before transitioning to a lower level of care. The enrollee continues to receive
acute care services, and these have not been denied. The medical record does not indicate that the enrollee
requires services that he is not currently receiving but that would be available at the LTACH facility. The
elements of the coverage rules 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 the LTACH services have not been met. Therefore, we decided that the Plan
does not have to provide coverage for long term acute care hospital (LTACH) services for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral-complete series of radiographic images (D0210) 
and the 2D oral/facial photogenic images (D0350 x 4) provided on March 21, 2023. 
  
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says these services are not covered under the 
supplemental dental policy. 
 
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 services provided are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the intraoral-
complete series of radiographic images (D0210) and the 2D oral/facial photogenic images (D0350 x 4) 
provided on March 21, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the thyroid stimulating hormone (TSH) (84443) provided 
December 29, 2022. 
 
You asked the Plan to pay for the laboratory service . You say that please review medical necessity as Z00.00 
is billed on the claim as well but his lab is deemed medically necessary with E78.2 on the claim as well. The 
Plan denied your request. The Plan says this testing is not covered by Medicare as a screening tool. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, the thyroid stimulating hormone, was requested solely for screening purposes. 
Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not 
have to pay for the thyroid stimulating hormone (TSH) (84443) provided December 29, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93042 billed for date of service February 11, 
2023. 
 
You asked the Plan to pay for the billed services. You say that the medical records support the level of services 
billed. The Plan denied your request. The Plan says the billed code 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 93042 is rhythm ECG, 1-3 leads; interpretation and 
report only. 
 
The file shows that 2 units of CPT code 93042 was billed. The Plan has agreed to pay for 1 unit of code 93042. 
We find that an additional unit of CPT code 93042 is not supported in the medical record for the date of service 
at issue. 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 code 93042 billed for date of 
service February 11, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on January 17, 2023, billed with 
codes 81209, 81223, 81250, 81305, 81320, and 81345. 
 
You asked the Plan to pay for the genetic testing billed. You say that you would like the Plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says panel testing should be billed using one 
CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
January 17, 2023, billed with codes 81209, 81223, 81250, 81305, 81320, and 81345.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator for 9 months (E0466). 
 
You asked the Plan to pre-approve a ventilator for 9 months. 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 for 9 months. Our reviewer 
says that the services are not medically necessary. Our physician reviewer found continuation of the home 
ventilator is not medically necessary. There is no evidence that bilevel positive airway pressure (BiPAP) with 
average volume assured pressure support (AVAPS) has been tried and failed as an outpatient. Medicare does 
not cover a home ventilator when used at settings that can be provided with BiPAP. The plan has approved the 
ventilator for 3 months, which provides time for transition to 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 for 9 months have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a ventilator for 9 months (E0466).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bone replacement graft for ridge preservation - per site 
(D7953) provided on March 6, 2023. 
 
You asked the Plan to pay for the extractions and bone replacement graft for ridge preservation. You say that 
the services were rendered for medical necessity, and you had no other choice but to go to a dentist out of 
network. The Plan denied your request. The Plan says the bone replacement graft for ridge preservation is not 
covered by your 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 pay for the bone 
replacement graft for ridge preservation - per site (D7953) provided on March 6, 2023.