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

 
We decided that the Plan does not have to pay for an additional unit of procedure code 87634 rendered on 
January 4, 2023. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the records submitted do not indicate that two separate services were performed/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 87634 is "Infectious agent detection by nucleic acid 
(DNA or RNA); respiratory syncytial virus, amplified probe technique." 
 
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 the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that no provider records have been 
identified for review.  As such, there is no explanation why an expanded respiratory testing panel was 
medically necessary for this patient.  As most viral illnesses have no specific treatment, identifying a causal 
virus is unlikely to change the course of treatment. The documentation does not support that the additional 
provided panel testing was medically necessary or reasonable. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for an additional unit of procedure code 87634 rendered on January 4, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for local anesthesia in conjunction with operative or surgical 
procedures (D9215) provided on April 28, 2023. 
 
You asked the Plan to pay for local anesthesia in conjunction with operative or surgical procedures (D9215). 
You say that you wonder why the dental Plan does not allow anesthesia to the patients. The Plan denied your 
request. The Plan says local anesthesia in conjunction with operative or surgical procedures (D9215) is not 
covered under the member's contract under any normal circumstances. 
 
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 local 
anesthesia in conjunction with operative or surgical procedures (D9215) provided on April 28, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99349 provided on February 23, 2023. 
 
You asked the Plan to pay for procedure code 99349. You say that the medical records support the billing of 
code 99349. The Plan denied your request. The Plan says the medical records do not support the billing of code 
99349. 
 
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 99349 is Home or residence visit for the evaluation and 
management of an established patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using total time on the date of the encounter for code 
selection, 40 minutes must be met or exceeded. 
 
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 99349. Our reviewer says that the medical 
records do not support the billing of code 99349. Our reviewer found the documentation supports an 
appropriate exam, but not an appropriate history or medical decision making of a moderate level. 
 
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 99349 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 99349 provided on February 23, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric care from August 26, 2023, 
forward. 
 
You asked the Plan to pre-approve inpatient psychiatric care from August 26, 2023, forward. You say that the 
services at issue were medically necessary. The Plan denied your request. The Plan says the services at issue 
were not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient psychiatric care from August 
26, 2023, forward. Our reviewer says that the enrollee does not meet the criteria for treatment in an acute 
inpatient mental health treatment beyond the date in question of August 26, 2023, forward. Our physician 
reviewer found the enrollee did not require inpatient mental health treatment beyond August 26, 2023, as she 
was not a danger to herself or others and did not have any delusions, auditory or visual hallucinations. It did not 
appear that active treatment was taking place beyond the date in question. It did not appear that the services for 
the dates in question were reasonably expected or medically necessary to improve the enrollees condition or 
for the purpose of diagnosis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient psychiatric care from August 26, 2023, forward have not been met. 
Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric care from August 26, 
2023, forward.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a footplate (K0108), footplate extension (K0108), 
footplate connector (K0108), accessory bar (K0108), and calf rest pads (E0995). 

You asked the Plan to pre-approve a footplate, footplate extension, footplate connector, accessory bar, and calf 
rest pads. You say that you are requesting reconsideration of the denied authorization. The Plan denied your 
request. The Plan says a foot plate cover and accessory bar do not serve a medical purpose. The Plan also says 
the other requested accessories are unbundled. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose. The rules also say miscellaneous options, accessories, or replacement parts for wheelchairs 
that do not have a specific HCPCS code and are not included in another code should be coded K0108.  
 
The request foot plate cover and accessory bar do not serve a purpose that is primarily medical in nature. The 
requested replacement calf rest pads (E0995) cannot be covered on initial issue. The request footplate 
accessories are unbundled and cannot be requested using code K0108. Therefore, we decided that the Plan does 
not have to pre-approve a footplate (K0108), footplate extension (K0108), footplate connector (K0108), 
accessory bar (K0108), and calf rest pads (E0995).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code A6209 provided on February 21, 2023. 
 
You asked the Plan to pay for procedure code A6209. 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. 
 
We find that CPT code A6209 is not supported in the medical record. Specifically, code A6209 is a surgical 
dressing code and was billed without an A1-A9 modifier. Based on this information, we decided that Medicare 
rules for coverage of procedure code A6209 has not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code A6209 provided on February 21, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the resin-based composite (D2392 and D2393) for tooth 
#28 and #29 and the extraction (D7210) for tooth #19. 
 
You asked the Plan to pre-approve the dental services. You say that the requested dental services are medically 
necessary. The Plan denied your request. The Plan says your benefit for the requested items or services has 
already been exhausted. 
 
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, certain limitations apply. The record 
shows the Plan paid for the resin-based composite (D2392 and D2393) for tooth #28 and #29 and the extraction 
(D7210) for tooth #19 on June 8, 2023; therefore, the enrollee's benefit for the requested items or services was 
exhausted on the date of service of June 8th, 2023. Therefore, we decided that the Plan does not have to pre-
approve the resin-based composite (D2392 and D2393) for tooth #28 and #29 and the extraction (D7210) for 
tooth #19.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the therapeutic exercises (97110 x 3) and chiropractic 
treatment to regions other than spine (98943 x 3) provided from May 3, 2022, to May 11, 2022. 
 
You asked the Plan to pay for chiropractic services. You say that these are covered benefits and should be paid. 
The Plan denied your request. The Plan says these chiropractic services are excluded from coverage. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the therapeutic exercises (97110 x 3) and chiropractic treatment to regions 
other than spine (98943 x 3) provided from May 3, 2022, to May 11, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connection between wheelchair controller 
and 2 or more power seating system motors (E2311), expandable controller (E2377), and a harness for upgrade 
to expandable controller (E2313). 
 
You asked the Plan to pre-approve an electronic connection, expandable controller, and a harness. You say that 
the services are necessary. The Plan denied your request. The Plan says medical necessity has not been 
established. Therefore, coverage criteria have not been met.  

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 electronic connection, expandable 
controller, and a harness. Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found the enrollee does not require non-
proportional input devices (e.g., sip and puff, head array, etc.), a separate display (i.e., for alternate control 
devices), other electronic devices (e.g., control of an augmentative speech device or computer through the 
chair's drive control), or an attendant control. The documentation does not support that it is medically necessary 
to control the requested power options through the joystick (drive interface). The enrollee's upper extremity 
strength and functional ability as evidenced by being supervision for feeding and grooming should be sufficient 
to control any power options through 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, expandable controller, and a harness have not been 
met. Therefore, we decided that the Plan does not have to pre-approve an electronic connection between 
wheelchair controller and 2 or more power seating system motors (E2311), expandable controller (E2377), and 
a harness for upgrade to expandable controller (E2313).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the 3 additional extractions, erupted tooth or exposed 
root (elevation and/or forceps removal) (D7140 x3). 
 
You asked the Plan to pre-approve the extractions. You say that you are in pain, have an infection, tooth 
sensitiveness, and a protruding bone. You also say that you can't afford to pay for the extractions. The Plan 
denied your request. The Plan says your benefit for the requested service has already been exhausted. 
 
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, certain limitations apply. The record 
shows your benefit for the requested service was exhausted on the appealed claim. Therefore, we decided that 
the Plan does not have to pre-approve the 3 additional extractions, erupted tooth or exposed root (elevation 
and/or forceps removal) (D7140 x3).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve removal of torus mandibularis (D7473), bone graft for 
repair of peri-implant defect - does not include flap entry and closure (D6103), and osseous surgery (including 
elevation of a full thickness flap and closure) - one to three contiguous teeth or tooth bounded spaces per 
quadrant (D4261). 
 
You asked the Plan to pre-approve the dental services represented by codes D7473, D6103, D4261. You say 
that you are requesting the services be reviewed under the medical benefit. The Plan denied your request. The 
Plan says these services are not covered under the benefit package. 
 
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 services are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve removal of 
torus mandibularis (D7473), bone graft for repair of peri-implant defect - does not include flap entry and 
closure (D6103), and osseous surgery (including elevation of a full thickness flap and closure) - one to three 
contiguous teeth or tooth bounded spaces per quadrant (D4261).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bone marrow aspirate (20939). 
 
You asked the Plan to pre-approve a bone marrow aspirate. You say that this 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 a 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 there is no specific indication provided to support the request for bone marrow 
aspirate for the approved surgery. There is a lack of large volume, long-term peer-reviewed outcome studies to 
support the use of bone marrow aspirate for this enrollee's medical condition as discussed above. 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 a bone marrow aspirate have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a bone marrow aspirate (20939).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connection (E2311), harness (E2313), and 
expandable controller (E2377). 
 
You asked the Plan to pre-approve an electronic connection, harness, and expandable controller. You say that 
you have been notified that only part of the motorized wheelchair has been approved. You also say that it is 
pertinent for the enrollee to have the additional at uptake shins for the motorized wheelchair including the 
ability to mobilize with the wheelchair from the controlled on the arm rest in order for the enrollee to be able to 
safely perform activities of daily living at home. The Plan denied your request. The Plan says this request 
exceeds the enrollee's need and is not reasonable and necessary per Medicare criteria. 
 
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 electronic connection, harness, and 
expandable controller. Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found the provided records document that the 
enrollee has fair upper extremity strength and is independent with feeding and meal preparation thus 
indicating they have adequate upper extremity strength and function to operate the wheelchairs 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, harness, and expandable controller have not been met. 
Therefore, we decided that the Plan does not have to pre-approve an electronic connection (E2311), harness 
(E2313), and expandable controller (E2377).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone marrow aspirate (20939). 
 
You asked the Plan to pre-approve bone marrow aspirate. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
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 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 no compelling rationale is presented or extenuating circumstances noted to support the medical necessity of this request as an exception. Therefore, the requested bone marrow aspirate 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 bone marrow aspirate have not been met. Therefore, we decided that the Plan 
does not have to pre-approve bone marrow aspirate (20939).
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve a home ventilator (E0466).

You asked the Plan to pre-approve a home ventilator. You say that the enrollee suffers with chronic obstructive pulmonary disease chronic and chronic respiratory failure. The enrollee has been on her ventilator since July 2021. The Plan denied your request. The Plan says that the request for continued use of a ventilator is not medically reasonable and necessary.

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. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as not reasonable and 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 a home ventilator. Our reviewer says that the service is not medically necessary. Our physician reviewer found the enrollee has chronic respiratory failure and has been on home ventilator for many years and compliant. To change therapies and change a beneficial therapy for this enrollee will be substandard of care. Documentation does support the medical necessity and rationale for ventilator. The ventilator can be used as average volume assured pressure support (AVAPS), which may be provided with BiPAP therapy. Best practice is to continue the therapy that is already treating the enrollee and shows success.

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 ventilator have been met. Therefore, we decided that the Plan has to pre-approve a home ventilator (E0466).

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 bone marrow aspirate (20939). 
 
You asked the Plan to pre-approve bone marrow aspirate. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
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 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 bone 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 bone marrow aspirate have not been met. Therefore, we decided that the Plan 
does not have to pre-approve bone marrow aspirate (20939).