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

 
We decided that the Plan does not have to pre-approve implantation or replacement of carotid sinus Baroreflex 
activation device; total system (0266T), and implantable neurostimulator (C1825). 
 
You asked the Plan to pre-approve the implantation of a Barostim Neo system. You say that the requested 
services are medically necessary. The Plan denied your request. The Plan says there is insufficient clinical peer 
reviewed literature demonstrating the safety, efficacy, and the effects of the Barostim device, on long-term 
health outcomes for people when done for congestive heart failure. 
 
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 implantation of a Barostim Neo 
system. Our reviewer says that the requested services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found Baroreflex stimulation devices have been considered potential alternative treatments for resistant hypertension and heart failure. The Barostim Neo system is an electronic 
pulse generator implanted underneath the clavicle with a lead tunneled under the skin to the carotid sinus in the 
neck. The pulse generator delivers electrical impulses, analogous to a cardiac pacemaker, to the baroreceptors 
of one of the carotid arteries. In August 2019 the Food and Drug Administration (FDA) approved the system 
for use in patients with refractory heart failure who remain symptomatic despite treatment with guideline-
directed medical therapy, are NYHA Class III, have an ejection fraction less than 35%, and are not candidates 
for bi-ventricular pacing. This was based on a clinical study demonstrating improvement in normal daily 
activities, distance walked, quality of life, and improved cardiac levels biomarker levels. This enrollee has 
symptoms thought to be due to chronic systolic heart failure (CHF) despite medical management, in the setting 
of severely reduced left ventricular function. There remains an absence of randomized, blinded clinical studies 
examining long-term clinical outcomes establishing the value of Barostim Neo in patient management. As a 
result, at this time the Barostim Neo system would not be considered medically reasonable and necessary in 
this enrollee's clinical management. 
 
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 implantation of a Barostim Neo system have not been met. Therefore, we 
decided that the Plan does not have to pre-approve implantation or replacement of carotid sinus Baroreflex 
activation device; total system (0266T), and implantable neurostimulator (C1825).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connection between wheelchair controller 
and two or more power seating system motors (E2311), a harness (E2313) and an expandable controller 
(E2377). 
 
You asked the Plan to pre-approve an electronic connection between wheelchair controller and two or more 
power seating system motors, a harness and an expandable controller. You say that these items are medically 
necessary. The Plan denied your request. The Plan says the enrollee is able to operate the independent power 
option controls of the requested power seating options. 
 
The Plan follows Medicare rules. Medicare rules say that these power wheelchair features are covered when the 
criteria in the rules section of this letter 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 an electronic connection between 
wheelchair controller and two or more power seating system motors, a harness and an expandable controller. 
Our reviewer says that these items are not medically necessary. Our physician reviewer found that the enrollee 
has sufficient strength and function in upper extremities to manage standard power drives. Thus, these extra 
features are 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 an electronic connection between wheelchair controller and two or more power 
seating system motors, a harness and an expandable controller have not been met. Therefore, we decided that 
the Plan does not have to pre-approve an electronic connection between wheelchair controller and two or more 
power seating system motors (E2311), a harness (E2313) and an expandable controller (E2377).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for  infectious-agent testing for chlamydia trachomatis (87491) 
billed for date of service April 5, 2023. 
 
You asked the Plan to pay for infectious-agent testing. You say that you have billed the service 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 the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of infectious-agent testing have been met. 
Specifically, a laboratory report that included results of the testing at issue was not provided for review. 
Therefore, we decided that the Plan does not have to pay for  infectious-agent testing for chlamydia trachomatis 
(87491) billed for date of service April 5, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 96127 billed for date of service June 13, 
2023.  
 
You asked the Plan to pay for procedure code 96127. You say that the enrollee responsibility should be $0. The 
Plan denied your request. The Plan says payment for code 96127 is bundled into payment for code G0439. 
 
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 96127 
is a column two code to column one code G0439 with a modifier indicator of 0. The column two 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 procedure code 96127 billed for date of service June 13, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a consultation (D9310) provided on July 26, 2023. 
 
You asked the Plan to pay for the dental service. You say that there should be a 100% coverage for the dental 
services. The Plan denied your request. The Plan says the denial of payment for this service is correct, because 
the consultation is not covered by the Plan. 

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 item or service is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a 
consultation (D9310) provided on July 26, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wound PCR panel provided March 7, 2023, billed with 
codes 87798-59 x13, 87801-59, 87801, 87481-59, 87551-59, 87150-59 x11.  

You asked the Plan to pay for the laboratory testing. You say that you request for review of the supporting 
documentation and processing of the claim for immediate reimbursement. 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. 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. This was a panel that was not billed with a single panel code as 
required. The services were unbundled. However, one unit of code 87801-59 x 1 was approved by the Plan.  
This code represents "Infectious agent detection by nucleic acid (DNA or RNA), multiple organisms; amplified 
probe(s) technique." This code is plural by definition. Based on this information, we decided that Medicare 
rules for coverage of the laboratory testing have not been met. Therefore, we decided that the Plan does not 
have to pay for the wound PCR panel provided March 7, 2023, billed with codes 87798-59 x13, 87801-59, 
87801, 87481-59, 87551-59, 87150-59 x11.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a crown (D2740) for tooth #24 and to pay for a crown 
(D2740) for tooth #21, 22, 27, and #28 provided on May 17, 2023. and July 3, 2023. 
 
You asked the Plan to pay more for the dental service. You say that the dental services should be covered. The 
Plan denied your request. The Plan says your annual dental maximum benefit for the year 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 Plans 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 $1,414 for dental services on March 27, 2023. On May 17, 2023, the Plan paid $2,727 for 
dental services. On July 12, 2023, the Plan paid $859 for dental services. For the year of 2023 the Plan paid 
$5,000 ($1,414 paid + $2,727 paid + $859 paid); therefore, your annual dental maximum benefit for the year of 
2023 was exhausted on the date of service of May 17, 2023. Therefore, we decided that the Plan does not have 
to pay more for a crown (D2740) for tooth #24 and to pay for a crown (D2740) for tooth #21, 22, 27, and #28 
provided on May 17, 2023. and July 3, 2023.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve surgical extractions for teeth #3, 4, 5, 6, 11, 12, 13, 17, 21 and 22 
(D7210). 
 
You asked the Plan to pre-approve the dental services. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says that the services denied correctly as they 
do not meet the clinical requirements to be approved. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers the dental 
services when the services are medically necessary and reasonable. 
 
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 dental services. Our physician 
reviewer found that the record indicates the teeth in dispute meet the clinical requirements to fall under surgical 
extractions. Criteria are met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the dental services have been met. Therefore, we decided that the Plan has to 
pre-approve surgical extractions for teeth #3, 4, 5, 6, 11, 12, 13, 17, 21 and 22 (D7210).  
 
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: Favorable

We decided that the Plan has to pre-approve Blood ketone test or reagent strips (A4252) provided on May 1, 2023.

You asked the Plan to pre-approve the blood ketone test or reagent strips. You say that the items should be covered as you disagree with the denial. The Plan denied your request. The Plan says that the items denied correctly as they are excluded from Medicare coverage.

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. the Plan's contract is ambiguous in it's wording and does not specifically exclude blood ketone strips. Therefore, we decided that the Plan has to pre-approve Blood ketone test or reagent strips (A4252) provided on May 1, 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health physical therapy (G0151 x8), and home 
health occupational therapy (G0152 x3). 
 
You asked the Plan to pre-approve home health services. You say that this is medically necessary. The Plan 
denied your request. The Plan says the services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found that the 
number of authorized visits is a clinically reasonable number of visits to progress from stand by assist or 
supervision to modified independent. The provider has not provided a rationale for the number of visits 
requested consistent with her prior response to therapy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home health physical therapy (G0151 x8), and home health occupational therapy 
(G0152 x3).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connection between wheelchair controller 
and two or more power seating system motors (E2311), a harness (E2313), an expandable controller (E2377) 
and an adjustable height, detachable armrest, complete assembly (E0973). 
 
You asked the Plan to pre-approve wheelchair accessories. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the enrollee does not meet criteria for approval of the requested accessories. 
 
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 wheelchair accessories. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the requested accessories exceed the enrollees medical needs and are not medically 
necessary, 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 
enrollee is independent in grooming, hygiene, eating, instrumental activities of daily living (IADLs). The 
enrollees upper extremity strength and functional ability are sufficient to control any power options with their 
own switches. An adjustable height, detachable armrest, complete assembly (E0973) exceeds the enrollees 
needs and is not medically necessary as armrests were included in the approved E1007 power tilt and recline. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of wheelchair accessories have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an electronic connection between wheelchair controller and two or more power 
seating system motors (E2311), a harness (E2313), an expandable controller (E2377) and an adjustable height, 
detachable armrest, complete assembly (E0973).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 36556 for date of service March 4, 2023. 
 
You asked the Plan to pay for procedure code 36556. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services billed are 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 36556 is insertion of non-tunneled centrally inserted 
central venous catheter; age 5 years or older. 
 
We find that CPT code 36556 is not supported in the medical record. Specifically, the medical records 
submitted indicate that a central line was placed. However, the records did not include documentation of the 
catheter entry site nor the final position of the tip of the central venous device. This means this code is not 
supported. Based on this information, we decided that Medicare rules for coverage of procedure code 36556 
have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 36556 for date 
of service March 4, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99203) and the x-ray of the lower and sacral 
spine (72100) provided by a chiropractor on Mary 7, 2023 to, June 22, 2023. 
 
You asked the Plan to pay for the office visit (99203) and the x-ray of the lower and sacral spine (72100). You 
say that before the treatment you could not put on your socks and now you are able to function as normal. The 
Plan denied your request. The Plan says the only covered chiropractic service is manual manipulation of the 
spine. 
 
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 office visit (99203) and the x-ray of the lower and sacral spine (72100) provided by a chiropractor on Mary 7, 2023 to, June 22, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a protective outer surface covering system (L5964). 
 
You asked the Plan to pre-approve a protective outer surface covering system (L5964). You say that the 
requested protective outer surface covering system (L5964) is medically necessary.  The Plan denied your 
request. The Plan says the enrollee does not meet criteria for a protective outer surface covering system 
(L5964). 
 
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 protective outer surface covering 
system (L5964). Our reviewer says that the enrollee does not meet criteria for a protective outer surface 
covering system (L5964). Our physician reviewer found there is no documentation from the physician that 
supports that the enrollee's prosthesis is exposed to harsh environmental situations or that they engage in any 
extraordinary activities that would justify the need for extra protection with a flexible outer surface covering 
system (L5964). The physician documentation does not support that the enrollee requires support beyond the 
approved L5705 cover. The criteria have not been met per policy article A52496. 
 
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 protective outer surface covering system (L5964) have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a protective outer surface covering system 
(L5964).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation (64625), fluoroscopic guidance 
for needle placement (77002) and an injection, methylprednisolone acetate (J1040). 
 
You asked the Plan to pre-approve sacroiliac (SI) radiofrequency ablation. You say that the enrollee is in 
severe pain, and you believe the procedure is medically necessary. The Plan denied your request. The Plan says 
the records do not show that the current medical literature supports the use of radiofrequency ablation in the 
treatment of sacroiliitis. 
 
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 sacroiliac (SI) radiofrequency ablation. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found the enrollee has low back pain and sacroiliitis. He has had prior SI joint 
injections with good result. This is considered an experimental procedure because of the wide variation in 
efficacy reported in the peer reviewed 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 sacroiliac (SI) radiofrequency ablation have not been met. Therefore, we 
decided that the Plan does not have to pre-approve radiofrequency ablation (64625), fluoroscopic guidance for 
needle placement (77002) and an injection, methylprednisolone acetate (J1040).