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

 
We decided that the Plan does not have to pre-approve a home ventilator.  
 
You asked the Plan to pre-approve a home ventilator. You say that the features available on the requested 
ventilator are not available on other devices. The Plan denied your request. The Plan says a home ventilator is 
not medically necessary. The patient's needs can be met with a bilevel positive airway pressure (BiPAP) device 
with average volume-assured pressure support (AVAPS). 
 
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 home ventilator. Our reviewer says 
that a home ventilator is not medically necessary. Our physician reviewer found the enrollee has a diagnosis of 
chronic obstructive pulmonary disease. The medical records submitted on appeal indicates that she was 
initiated on a non-invasive ventilator (NIV) on December 1st, 2017. The NIV was ordered in the AVAPS-AE 
mode. The compliance data submitted from the time period of April 5th, 2023, to May 4th, 2023, indicates the 
machine is being used in AVAPS-AE mode, and no other modes. She was evaluated by her provider in the 
office on May 16th, 2023, and the office visit notes say she is to continue to use oxygen and the NIV at night. 
The documentation submitted fails to indicate that she is requiring the NIV for use in other than bilevel positive 
airway pressure (BiPAP) or BiPAP with AVAPS mode. The records received from the provider do not say that 
she has failed the use of BIPAP or BIPAP with AVAPS when she is at her baseline level of breathing. 
 
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 not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental code D9215. 
 
You asked the Plan to pre-approve dental code D9215. You say that you would like the Plan to reconsider their 
denial. The Plan denied your request. The Plan says dental code D9215 is not covered by Medicare or the 
Plan's supplemental dental benefit. 
 
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, 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 code D9215.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Flex system face-down positioning table. 
 You asked the Plan to pre-approve these services. You say that you underwent eye surgery and the device will 
help as a precautionary measure. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature and is not a 
preventive service that is covered by Medicare. Therefore, we decided that the Plan does not have to pre-
approve a Flex system face-down positioning table.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99183 and G0277 for date of service 
January 16, 2023, to January 24, 2023. 
 
You asked the Plan to pay for procedure codes 99183 and G0277. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the services are not payable as billed. 
 
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 code 99183 and G0277 is not supported in the medical record. Specifically, these services 
were billed with diagnosis codes I73.9 (Peripheral vascular disease, unspecified) and I70.633 (Atherosclerosis 
of nonbiological bypass graft(s) of the right leg with ulceration of ankle). These diagnosis codes should not be 
billed together. The claim is not payable as billed. Based on this information, we decided that Medicare rules 
for coverage of procedure codes 99183 and G0277 have not been met.  Therefore, we decided that the Plan does not have to pay for procedure codes 99183 and G0277 for date of 
service January 16, 2023, to January 24, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure.  
 
You asked the Plan to pre-approve the Intracept procedure. You say that the Intracept procedure is medically 
necessary. The Plan denied your request. The Plan says the Intracept procedure is not medically necessary.  
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve  the Intracept procedure. Our reviewer 
says that the requested the Intracept procedure is not considered medically reasonable and necessary in this 
case. Our physician reviewer found there is no magnetic resonance imaging (MRI) showing only Modic 
changes without foraminal stenosis or facet joint syndrome. The cause of the back pain is not clear. 
 
 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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve a home ventilator. You say that the patient requires a home ventilator to 
assist in his breathing. The Plan denied your request. The Plan says a home ventilator is not medically 
necessary. The patient's needs can be met with a bilevel positive airway pressure (BiPAP) device with average 
volume-assured pressure support (AVAPS). 
 
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 home ventilator. Our reviewer says 
that a home ventilator is not medically necessary. Our physician reviewer found the enrollee has a diagnosis of 
chronic obstructive pulmonary disease (COPD). The medical records submitted on appeal indicates that the 
enrollee was prescribed a non-invasive ventilator (NIV) since June of 2021. The NIV was ordered in the 
AVAPS-AE mode. With this request for continuation of the NIV, there was no change in the order for the 
device, or in the settings requested according to the standard written order dated June 22,2023. The compliance 
data submitted by the durable medical equipment provider from the time period of January 24, 2023, to March 
17,2023, indicates the machine is being used in AVAPs-AE mode, and no other modes. It also shows that the 
enrollee is using it 7 hours in a day for 100% usage during the 51 days. He was evaluated by his provider in the 
office for a telehealth visit on April 11,2023 and the office visit notes state that he has COPD and to continue 
NIV. The documentation submitted fails to indicate that he is requiring the NIV for use in other than bilevel 
positive airway pressure (BiPAP) or BiPAP with AVAPS mode. The records received do not say that the 
enrollee has failed the use of BIPAP with AVAPS in the home of hospital setting. 
 
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 not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill 
(SSBCI).  
 
You asked the Plan to pre-approve SSBCI benefits. You say that you need these additional benefits. The Plan 
denied your request. The Plan says the criteria for eligibility have not been met.  
 
The Plan must follow Medicare rules. Medicare rules say that, to qualify for SSBCI, an enrollee must have a 
documented chronic condition that is life threatening or significantly limits the health or function of the 
enrollee, has a high risk of hospitalization or adverse health outcomes, and requires intensive care coordination.  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of SSBCI benefits have not been met. Specifically, we have confirmed that you do not have an 
eligible condition that meets all the required criteria. Therefore, we decided that the Plan does not have to pre-
approve special supplemental benefits for the chronically ill (SSBCI).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 27487 provided on September 23, 2022. 
 
You asked the Plan to pay for procedure code 27487. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the billed code is 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 CPT code. 
 
We find that CPT code 27487 is not supported in the medical record. Specifically, this code has a status 
indicator of "C" and was billed on the same day as an inpatient procedure. The record does not show this is a 
separate procedure. Based on this information, we decided that Medicare rules for coverage of procedure code 
27487 have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 27487 
provided on September 23, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided January 14, 2023, to 
February 10, 2023. 
 You asked the Plan to pay for the home health services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the NOA was not received timely. As such, this final claim was 
correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is January 14, 2023. The NOA was not received by the Plan until April 11, 
2023. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for the home health services 
provided January 14, 2023, to February 10, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dual-energy x-ray absorptiometry (DXA) study provided 
on January 16, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the dual-energy x-ray absorptiometry (DXA) study. You say that you disagree 
with the Plan's denial. The Plan denied your request. The Plan says the services provided are not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider at issue in this case is not a network provider with the Plan. 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 
dual-energy x-ray absorptiometry (DXA) study have not been met.  
 
The Plan has network providers available who can provide the items/services at issue in this appeal. We found 
no exception that would require the Plan to pay for the dual-energy x-ray absorptiometry (DXA) study. 
Therefore, we decided that the Plan does not have to pay for the dual-energy x-ray absorptiometry (DXA) 
study provided on January 16, 2023, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve kyphoplasty (99153, 22513, 99152). 
 You asked the Plan to pre-approve kyphoplasty. 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 Percutaneous Vertebral Augmentation (PVA) for 
Osteoporotic Vertebral Compression Fracture (VCF) is 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 the 
services are not medically necessary. Our physician reviewer found there is no trial of bracing. More 
conservative measures are 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 kyphoplasty have not been met. Therefore, we decided that the Plan does not 
have to pre-approve kyphoplasty (99153, 22513, 99152).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for assistant surgeon services provided for procedure code 
21930 for date of service June 3, 2022. 
 
You asked the Plan to pay for assistant surgeon services provided for procedure code 21930. You say that you 
disagree with the Plan's denial. The Plan denied your request. The Plan says the services are not payable as 
billed. 
 
The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, 
assistant surgeon services are not covered. In this case, you billed assistant surgery services for Current 
Procedural Terminology (CPT) code 21930. The Medicare Fee Schedule Database contains a surgical indicator 
of 1 for this procedure. This means that Medicare has determined that an assistant surgeon is not medically 
necessary and will not be paid.  Based upon this information, we find that Medicare coverage criteria for assistant surgeon services provided 
for procedure code 21930 have not been met. Therefore, we decided that the Plan does not have to pay for 
assistant surgeon services provided for procedure code 21930 for date of service June 3, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 64713 billed for date of service January 24, 
2023.  
 You asked the Plan to pay for procedure code 64713. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed.  
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI val1 
 
In this case, the MUE for CPT code 64713 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 64713 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 64713 billed for date of service January 24, 2023.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided from October 28, 2022, to 
January 9, 2023. 
 
You asked the Plan to pay for the psychotherapy. The Plan denied your request. The Plan says this provider is 
not part of the Medicare program. 
 
The Plan must follow Medicare rules. Medicare rules say that a Mental Health Counselor is not eligible to 
participate in the Medicare program. 
 
We looked at the file and Medicare rules. The provider at issue in this case is a Mental Health Counselor. 
Medicare says that a Mental Health Counselor is not eligible to participate in the Medicare program. Therefore, 
we decided that the Plan does not have to pay for psychotherapy provided from October 28, 2022, to 
January 9, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on December 9, 2022. 
 
You asked the Plan to pay for the lab services. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on December 9, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on November 29, 2022. 
 
You asked the Plan to pay for the lab services. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on November 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on December 29, 2022. 
 
You asked the Plan to pay for the office visit. You say that this provider is very qualified to treat jaw 
conditions, including your temporomandibular jaw osteoarthritis and no other provider in greater Sacramento 
would accept you as a patient. The Plan denied your request. The Plan says the service received by the member 
was rendered by a provider who is not under contract with the health Plan and is opted out of Medicare. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for an office 
visit provided on December 29, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for GeneSight Psychotropic test (81479) provided May 19, 
2022. 
 
You asked the Plan to pay for the genetic testing. You say that no basis exists for a Medicare Advantage Plan 
to deny coverage of a service that is covered by Medicare. 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 the genetic testing 
have not been met. Therefore, we decided that the Plan does not have to pay for GeneSight Psychotropic test 
(81479) provided May 19, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for dialysis services provided in Mexico from 
November 26, 2022, to November 28, 2022. 
 
You asked the Plan to reimburse you for the dialysis services. You say that you had to travel to Mexico for 
family issues and there was no option but to find a dialysis clinic where you were in Mexico. The Plan denied 
your request. The Plan says dialysis is not covered outside the US and its territories and excluded from 
coverage under the Plan. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan says that pre-scheduled, pre-planned treatments (including chronic dialysis) for any 
ongoing chronic conditions and/or elective procedures are not covered outside the US and its territories. 
 
We looked at the file and the Plans rules. The Plan says that pre-scheduled, pre-planned treatments  
(including chronic dialysis) for any ongoing chronic conditions and/or elective procedures are not covered 
outside the US and its territories. Therefore, we decided that the Plan does not have to reimburse you for 
dialysis services provided in Mexico from November 26, 2022, to November 28, 2022.
Appeal type: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to pay for the home health services provided on February 3, 2023. 
 
You asked the Plan to pay for the home health services as billed. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the claim was not billed correctly. 
 
The Plan follows Medicare rules. The rules say that home health services must be billed with correct 
information. 
 
We reviewed the file and the Medicare rules. Review of the file shows that these services were billed with an 
invalid type of bill. The claim is also missing G and Q codes for these home health services. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided on February 3, 2023.