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

 
We decided that the Plan has to pay for procedure codes 31276 and 31267 provided on July 12, 2023. 
 
You asked the Plan to pay for procedure codes 31276 and 31267. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says that the services are not 
covered as billed. 
 
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. We find that the Plan has not provided enough evidence to support the denial of 
payment for procedure codes 31276 and 31267 based on Medicare criteria. The Plan denied these codes for 
being bundled into other codes billed; however, the Plan did not specify which code they are bundled with. In 
looking up the procedure codes billed, we found no National Correct Coding Initiative (NCCI) edits between 
procedure codes 31276 and 31267, and the other codes billed on the claim at issue. Therefore, we decided that 
the Plan has to pay for procedure codes 31276 and 31267 provided on July 12, 2023.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a reaching/grabbing device (A9281). 
 
You asked the Plan to pre-approve the reaching//grabbing device. You say that the enrollee needs this. The 
Plan denied your request. The Plan says this is not a covered item. 
 
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. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a reaching/grabbing device (A9281).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99214), pelvic ultrasound (76857), 
transurethral ultrasound (76872), ultrasonic guidance for needle placement (76942), and biopsy (55700) 
provided on June 28, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the medical services. You say that you are Medicare providers. You say that this 
procedure was done in the office. You also say that Medicare does not require prior authorization. The Plan 
denied your request. The Plan says prior authorization was not obtained. 
 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 in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the services at issue in this appeal. The Plan did not pre-approve the item/service at 
issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that 
the Plan does not have to pay for the office visit (99214), pelvic ultrasound (76857), transurethral ultrasound 
(76872), ultrasonic guidance for needle placement (76942), and biopsy (55700) provided on June 28, 2023, by 
an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the paring or cutting of benign hyperkeratotic lesion services 
received from November 7, 2022, to February 28, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the paring or cutting of benign hyperkeratotic lesion services. You say that the 
enrollee was recommended to go to this wound clinic. The Plan denied your request. The Plan says the services 
received are not a covered benefit when received by an OON provider. 
 
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 requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the paring or cutting of benign hyperkeratotic 
lesion services received from November 7, 2022, to February 28, 2023, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the guided tissue regeneration, natural teeth  resorbable 
barrier, per site tooth #'s 14 (D4266). 
 
You asked the Plan to pre-approve the guided tissue regeneration. You say that the enrollee's condition 
necessitating the service is clear per the submitted x-ray, and the bone graft and resorbable barrier are needed in 
order to make a bridge. You also say that tooth #14 needs to be extracted and will have a huge void in the bone.  The Plan denied your request. The Plan says the records do not show that this is needed to hold a crown, but 
instead to correct an irregularity.  
 
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 guided 
tissue regeneration 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 guided tissue regeneration. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found the x-rays included 
show tooth #14 with severe bone loss around the tooth and tartar on the root surfaces of the tooth. According to 
the American Dental Association (ADA) claim form dated November 15, 2023, there is a request for coverage 
to extract tooth #14. Based on the information provided, D4266 for tooth #14 is not medically reasonable or 
necessary as the tooth is planned for extraction. Per the Current Dental Technology (CDT) code definition of 
D4266, this code is associated with a natural tooth, and since tooth #14 is to be extracted, this code does not 
apply. There are other codes that may be more applicable. Please review the American Dental Association 
CDT booklet. 
 
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 guided tissue regeneration have not been met. Therefore, we decided that 
the Plan does not have to pre-approve the guided tissue regeneration, natural teeth  resorbable barrier, per site 
tooth #'s 14 (D4266).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgical placement of implant body (D6010 x2), a 
prefabricated abutment (D6056 x2) and an implant supported crown (D6066 x2). 
 
You asked the Plan to pre-approve the implant services. You say that you have a problem eating and chewing 
because you do not have enough teeth. You say you have lost 44 pounds of weight in the last few weeks due to 
dental issues. The Plan denied your request. The Plan says these services are not covered under your benefit 
plan. 
 
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 
surgical placement of implant body (D6010 x2), a prefabricated abutment (D6056 x2) and an implant 
supported crown (D6066 x2).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve urology supplies to be provided by an out-of-network 
(OON) provider.  
 
You asked the Plan to pre-approve OON services. You say that the enrollee wants to use a local provider. The 
Plan denied your request. The Plan says medically necessary care is available in network. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items at issue in this appeal. We found no exception that would require the Plan 
to pre-approve these OON services. Therefore, we decided that the Plan does not have to pre-approve urology 
supplies to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eye exam with refraction provided on August 22, 2023. 
 
You asked the Plan to pay for the eye exam with refraction. You say that in January 2023, you were told by 
your doctor that you had cataracts and needed cataract surgery. You also say that you contacted the Plan and 
were advised another eye exam would be covered, and you went for a post-cataract eye exam to get a new 
prescription for glasses. The Plan denied your request. The Plan says the maximum benefit has been exceeded, 
and this claim processed correctly. The Plan also says that the provider confirmed you were not seen for 
anything other than a routine exam. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers up to one non-Medicare-covered routine eye exam every year. 
 
 We looked at the file and the Plan's rules. The record shows that you received a routine eye exam on January 9, 
2023, and your routine eye exam benefit had been exhausted. Based on this information, we decided that the 
Plan's rules for coverage of the eye exam with refraction have not been met. Therefore, we decided that the 
Plan does not have to pay for the eye exam with refraction provided on August 22, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve neurology services to be provided by an out-of-network 
(OON) provider.  
 
You asked the Plan to pre-approve OON services. You say that a network provider made your condition worse. 
The Plan denied your request. The Plan says there are network providers available. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these OON services. Therefore, we decided that the Plan does not have to pre-approve 
neurology services to be provided by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve T10 and T12 kyphoplasties. 
 
You asked the Plan to pre-approve the T10 and T12 kyphoplasties. You say that the enrollee has several spinal 
fractures. You also say that this is medically necessary. The Plan denied your request. The Plan says there is no 
documented acute or subacute VCF present at T10 and T12. 
 
The Plan follows Medicare rules. Medicare rules say that a kyphoplasty may be covered when an acute (less 
than 6 weeks) or subacute (6 to 12 weeks) osteoporotic vertebral compression fracture (VCF) is present based 
on symptom onset, and documented by advanced imaging. 
 
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 kyphoplasties. Our reviewer says 
that the requested T10 and T12 kyphoplasties are not medically necessary. Our physician reviewer found the 
provided documentation does not indicate acute or subacute fractures at T10 and T12. Therefore, the reviewer 
found that the requested kyphoplasties are 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 the kyphoplasties have not been met. Therefore, we decided that the Plan does 
not have to pre-approve T10 and T12 kyphoplasties.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve MLH1 gene sequencing (81292), MLH2 gene 
sequencing (81295) and MSH6 gene sequencing (81298). 
 
You asked the Plan to pre-approve genetic testing. You say that your provider strongly recommended these 
tests due to your family history of cancer. The Plan denied your request. The Plan says your provider has 
indicated that these tests would be performed as a screening. These tests are not covered for screening 
purposes. 
 
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, genetic testing, is being 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 pre-
approve MLH1 gene sequencing (81292), MLH2 gene sequencing (81295) and MSH6 gene sequencing 
(81298).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor. You asked the Plan to pre-approve the requested device. The Plan denied your request. The Plan says coverage 
criteria have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary when prescribed in accordance with their FDA indications for enrollees with diabetes 
who are insulin treated or who have a history of problematic hypoglycemia, and have had an in-person visit 
with their treating physician to evaluate their diabetes control and determine whether the criteria for coverage 
have been met. 
 
We looked at the file and Medicare rules. The documentation does not show that the enrollee uses insulin or 
has a history of problematic hypoglycemia. Based on this information, we decided that Medicare rules for 
coverage of the requested device have not been met. Therefore, we decided that the Plan does not have to pre-
approve a continuous glucose monitor.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgical placement of implant body (D6010) and an 
implant supported porcelain/ceramic crown (D6065). 
 
You asked the Plan to pre-approve the implant services. You say that there is no other alternative treatment to 
help you, and the dentist states the only thing that can be done is an implant. The Plan denied your request. The 
Plan says this service is not covered in your 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 
surgical placement of implant body (D6010) and an implant supported porcelain/ceramic crown (D6065).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve VivAer procedure. 
 
You asked the Plan to pre-approve VivAer procedure. You say that this is medically necessary. The Plan 
denied your request. The Plan says the clinical value and effectiveness of the VivAer procedure in the setting of 
nasal turbinate hypertrophy has 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 VivAer procedure. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is insufficient literature to support the safety and efficacy of the requested 
service for the enrollee's specific conditions. The record provided does not establish the medical necessity and 
reasonableness, as defined by Medicare rules, of the requested service.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of VivAer procedure have not been met. Therefore, we decided that the Plan does 
not have to pre-approve VivAer procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99212 provided on December 26, 2020. 
 
You asked the Plan to pay for procedure code 99212. 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 many services within the postoperative period 
are considered to be included within payment for the global surgical procedure. 
 
We looked at the file and Medicare rules. The service at issue is within the global surgery period of code 97597 
provided on December 26, 2020. The documentation submitted does not support a significant, separately 
identifiable evaluation and management service to support the use of the -25 modifier. Therefore, we decided 
that the Plan does not have to pay for procedure code 99212 provided on December 26, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Urolift procedure (52441, 52442). 
 
You asked the Plan to pre-approve a Urolift procedure. 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 a Urolift procedure. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found based on the medical records provided there is no documentation that the Urolift 
procedure at issue in this case meets all Medicare criteria for medically reasonable and necessary and safe and 
effective for the enrollee. The manufacturer's documentation on the Urolift states: "Do not use if the patient has a known allergy to nickel, titanium, or stainless steel." Provided records in this case do not document the 
enrollee's allergies. Provided records also do not document failure of medical therapy for benign prostatic 
hyperplasia (BPH); records state the enrollee "has noticed improvement" with use of tamsulosin with no 
reported adverse effects. In addition, although the enrollee history reports no hematuria, the objective data 
provided do not clarify lack of hematuria with is reported by the manufacturer as a contraindication to the 
procedure. 
 
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 Urolift procedure have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a Urolift procedure (52441, 52442).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CxBladder testing (0012M) provided on July 6, 2023. 
 
You asked the Plan to pay for the CxBladder testing (0012M). 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. 
 
The Plan must follow Medicare rules. Medicare rules say that CPT codes 0012M and 0013M for CxBladder are 
non-covered.  
 
We looked at the file and Medicare rules. The service at issue is non-covered. Therefore, we decided that the 
Plan does not have to pay for the CxBladder testing (0012M) provided on July 6, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 power wheelchair with single power option 
(tilt) and accessories (E0955, E1002, E1012, E1028, E2311, E2313, E2361, E2377, E2603, K0856). 
 
You asked the Plan to pre-approve the durable medical equipment (DME). You say that the requested power 
wheelchair and its components are medically necessary for the enrollee. The Plan denied your request. The 
Plan says there is not a medical need for the requested power option. 
 
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 durable medical equipment (DME). 
Our physician reviewer found the enrollee has a mobility deficit that is unable to be helped by a manual 
wheelchair, walker, or cane due to pain, weakness, fatigue, and safety/fall risk issues. The enrollee has a Group 
3 neurological diagnosis. The documentation does not support that the enrollee is at high risk for development 
of a pressure ulcer, utilizes intermittent catheterization for bladder management, or needs a power seating 
system to manage increased tone or spasticity. The request for power seating system exceeds the enrollee's 
medical needs per LCD L33792. As the Group 3 power wheelchair K0856 with power tilt exceeds the 
enrollee's medical needs the additional accessories are not medically necessary per LCD: L33789. 
 
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 durable medical equipment (DME) have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a Group 3 power wheelchair with single power option (tilt) 
and accessories (E0955, E1002, E1012, E1028, E2311, E2313, E2361, E2377, E2603, K0856).