Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 96365, 963666, 96521 and J1817 billed for 
date of service February 8, 2023. 
 
You asked the Plan to pay for procedure codes 96365, 963666, 96521 and J1817. You say that you have billed 
the services at issue correctly. The Plan denied your request. The Plan says the provided records do not support 
the services 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. 
 
In this case, the CPT Code Manual definition of code 96365 is: Intravenous infusion, for therapy, prophylaxis, 
or diagnosis (specify substance or drug); initial, up to 1 hour. The definition of code 96366 is: Intravenous 
infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); each additional hour (List 
separately in addition to code for primary procedure). The definition of code 96521 is: Refilling and 
maintenance of portable pump. The definition of code J1817 is: Insulin for administration through dme (i.e., 
insulin pump) per 50 units. 
 
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 codes 96365, 963666, 96521 and J1817. Our 
reviewer says that procedure codes 96365, 963666, 96521 and J1817 do not meet criteria for payment. Our 
reviewer found that regarding codes 96365 and 96366, the medical records provided indicate that Outpatient 
Intravenous Insulin Treatment (OIVIT) was performed. OIVIT is a non-covered service nationally per 
Medicare. The medical record submitted includes an order for refilling and maintenance of portable pump; 
however, OIVIT treatment was performed and there was not documentation to validate that pump maintenance 
was performed, therefore code 96521 cannot be verified. The medical documentation submitted indicates that 
J1817 Nova R was administered intravenously and was part of OIVIT services, which is a nationally non-
covered service by Medicare; therefore, code J1817 is not eligible for reimbursement consideration. 
 
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 codes 96365, 963666, 96521 and J1817 have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure codes 96365, 963666, 96521 and J1817 
billed for date of service February 8, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve kyphoplasty (22514, 22515, 22513, 77002). 
 
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 both PVP and PVA will be considered reasonable and 
necessary for osteoporotic conditions when certain 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 you have multiple compression fractures of 
varying ages. Also, you have multilevel degenerative disc disease in the spine. The cause of the back pain is 
not clear. Kyphoplasty is not medically needed and has not been shown to have better outcomes than 
conservative measures. 
 
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 (22514, 22515, 22513, 77002).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve O2 Concept Oxlife Liberty portable oxygen concentrator (E1399).

You asked the Plan to pre-approve the oxygen equipment. You say that the lightweight concentrator would make it more likely the enrollee could manage everything on their own. The Plan denied your request. The Plan says medical necessity has not been established as the request is for a lighter O2 concentrator to ease walking and the ability to transport, which is a convenience.

The Plan must follow Medicare rules. The rules say that to qualify for portable oxygen, the patient must meet the criteria for home oxygen. The documentation must show that the patient is mobile in the home and would benefit from the use of portable oxygen in the home. Portable oxygen is not covered for patients who qualify for oxygen solely based on blood gas studies obtained during sleep.

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 oxygen equipment. 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 in this case indicate the patient is oxygen dependent although no blood gas or oxygen saturation reports are provided. The records do not include any clinical evidence that despite a level of oxygen saturation greater than 89%, supplemental oxygen is still medically necessary and reasonable. The records do not document that a standard portable oxygen concentrator would not meet the enrollee's medical needs and that the requested O2 Concept Oxlife Liberty portable oxygen concentrator is not a convenience item that would exceed their medical needs.

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 oxygen equipment have not been met. Therefore, we decided that the Plan does not have to pre-approve O2 Concept Oxlife Liberty portable oxygen concentrator (E1399).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve kyphoplasty spinal surgery. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found there is no trial of a fracture brace in 
the submitted documentation. More conservative measures are needed prior to surgery. The kyphoplasty is not 
reasonable or medically necessary at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve kyphoplasty spinal surgery.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a humidifier. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that a non-heated (E0561) or heated (E0562) humidifier is 
covered when ordered by the treating practitioner for use with a covered PAP (E0470 or E0601) device. 
 
We looked at the file and Medicare rules. The humidifier is not being requested for use with a covered positive 
airway pressure (PAP) device. Based on this information, we decided that Medicare rules for coverage of these 
services have not been met. Therefore, we decided that the Plan does not have to pre-approve a humidifier.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a kyphoplasty. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that kyphoplasty 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee is being treated for a 
wedge compression fracture of unspecified thoracic vertebra. The examination reveals pain and spasms of the 
lumbar spine. There is no detailed documentation of worsening pain. There is no indication of a progression of 
the body height loss at L2 and L3, kyphotic deformity, or a severe impact on her daily activities. Moreover, 
there is magnetic resonance imaging (MRI) corroboration of retropulsion at T12 and a lack of documentation 
that the compression fracture is acute or subacute. Therefore, the records do not support that the criteria for 
coverage are met. The kyphoplasty is not reasonable or medically 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a kyphoplasty.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the lower limb prosthetic components, a K3 
microprocessor knee and foot (L5845, L5848, L5856, L5981). 
 
You asked the Plan to pre-approve the items. You say that these components will provide increased stability 
and safety.  The Plan denied your request. The Plan says the enrollee has a current knee and foot that are under 
warranty and the requested components exceed the enrollee's medical needs. 
 
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 items. Our physician reviewer 
found the lower limb prosthetic components L5845, L5848, L5856, L5981, a K3 microprocessor knee and foot 
are not medically necessary per L33787 and per the Social Security Act, Section 1862 (a)1(A) and the 42 CFR 
Section 411.15(k), 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 
requested items exceed the enrollee's medical and functional need. The documentation indicates the enrollee's 
current knee and foot are still under warranty as they are under two (2) years old. The documentation does not 
support that the enrollee is a K3 ambulator given the history of using an assistive device and having falls and 
fatigue. The documentation from the treating physician do not support that the enrollee requires a heavier 
microprocessor knee over a mechanical knee.  
 
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 items have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the lower limb prosthetic components, a K3 microprocessor knee and foot (L5845, L5848, 
L5856, L5981).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a complete mandibular denture (D5120) purchased on 
December 29, 2023. 
 
You asked the Plan to pay for the dental services. You say that you were informed by the Plan before you got 
your dentures that they would be paid for. The Plan denied your request. The Plan says your benefit for the 
requested item or 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 item or service was exhausted on date of service November 21, 2019. 
Therefore, we decided that the Plan does not have to pay for a complete mandibular denture (D5120) purchased 
on December 29, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 7 additional units of neuropsychological testing. 
 
You asked the Plan to pre-approve 7 additional units of neuropsychological testing. You say that you would 
like the enrollee to have a neuropsychological testing to explore other causes for decline in memory and 
cognition. The Plan denied your request. The Plan says the number of units requested for this service is high 
based on the medical records and documentation of the enrollee's current treatment needs. 
 
The Plan follows Medicare rules. Medicare rules say that examples of problems that might lead to 
neuropsychological testing are listed in the Medicare rules section of this letter. 
 
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 7 additional units of 
neuropsychological testing. Our reviewer says that this enrollee does not meet the criteria for 7 additional units 
of neuropsychological testing. Our physician reviewer found this request is considered excessive as the enrollee 
was approved for 5 units along with an additional 10 units which include 1 unit of 96133, and 4 units of 96137. 
Our reviewer also found that it is therefore not medically necessary or reasonable to have an additional 7 units 
of neuropsychological testing. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 7 additional units of neuropsychological testing have not been met. Therefore, 
we decided that the Plan does not have to pre-approve 7 additional units of neuropsychological testing.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87801 billed for date of service December 
29, 2022. 
 
You asked the Plan to pay for procedure code 87801. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says payment for code 87801 is bundled into 
payment for code 87500. 
 
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 87801 
is a column II code to column I code 87500. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 87801 billed for date of service December 29, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit to be provided by an out-of-network 
(OON) provider.  
 
You asked the Plan to pre-approve an office visit . You say that the member should be seen by the proivder. The 
Plan denied your request. The Plan says this 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/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
an office visit to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a disposable drug pump (A9274). 
 
You asked the Plan to pre-approve a disposable drug pump (A9274). You say that you would like to request 
reconsideration of the denied authorization. The Plan denied your request. The Plan says the criteria for 
approval have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that disposable drug delivery systems are not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a disposable drug pump (A9274) have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a disposable drug pump (A9274).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93922 rendered on July 7, 2022. 
 
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 do not support the services 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. 
 
In this case, the CPT Code Manual definition of code 93922 is "Limited bilateral noninvasive physiologic studies of upper or lower extremity arteries, (eg, for lower extremity: ankle/brachial indices at distal posterior tibial and anterior tibial/dorsalis pedis arteries plus bidirectional, Doppler waveform recording and analysis at 1-2 levels, or ankle/brachial indices at distal posterior tibial and anterior tibial/dorsalis pedis arteries plus volume plethysmography at 1-2 levels, or ankle/brachial indices at distal posterior tibial and anterior tibial/dorsalis pedis arteries with, transcutaneous oxygen tension measurement at 1-2 levels)."

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 the documentation does not support that the service coded as CPT 93922 was provided. The code in question codes for a test using blood pressure cuffs and a Doppler machine, generally performed in a vascular testing lab, not in the operating room or interventional suite. The operative note gives no indication that such a test was performed. This appears to be a coding error.
 
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 procedure code 93922 rendered on July 7, 2022.  
 
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 procedure code 93922 rendered on July 7, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an all lower extremity prostheses, flex-walk system or
equal (L5981) and all lower extremity prostheses, multi-axial rotation unit (L5986) for the enrollee.
You asked the Plan to pre-approve these services. You say that these items are medically necessary. The Plan
denied your request. The Plan says that the member's physician documents no medical need for K3
components.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for an all lower
extremity prostheses, flex-walk system or equal and all lower extremity prostheses, multi-axial rotation unit.
Our Medical Director states that the clinical documentation does not support that the enrollee in this case was a
K3 ambulator and required K3 components. Our Medical Director found that the enrollee's condition does not
meet criteria for coverage of these services.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not
have to pre-approve an all lower extremity prostheses, flex-walk system or equal (L5981) and all lower
extremity prostheses, multi-axial rotation unit (L5986) for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an expandable controller upgrade (E2377), harness (E2313), and electronic connection (E2311) for the enrollee.
You asked the Plan to pre-approve an expandable controller upgrade, harness, and electronic connection. You say that these items are medically necessary. The Plan denied your request. The Plan says that the medical record shows that the member's upper limb strength and function are adequate for the member to be able to control the power options using their own switches.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for an expandable controller upgrade, harness, and electronic connection. Our Medical Director states that the documentation does not sufficiently support that it was medically necessary for the enrollee in this case to have an expandable controller upgrade (E2377), harness (E2313), and electronic connection (E2311).
Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of an expandable controller upgrade, harness, and electronic connection. 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 expandable controller upgrade, harness, and electronic connection have not been met. Therefore, we decided that the Plan does not have to pre-approve an expandable controller upgrade (E2377), harness (E2313), and electronic connection (E2311) for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an Ability Drive eye gaze control system (K0108) for the enrollee.
You asked the Plan to pre-approve an Ability Drive eye gaze control system. You say that this device is medically necessary. The Plan denied your request. The Plan says that coverage criteria has not been met.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for an Ability Drive eye gaze control system. Our Medical Director states that the documentation is insufficient to support that the Ability Drive eye gaze control system is medically reasonable and necessary for the enrollee in this case, as the case file does not contain clinical medical records. Our Medical Director found that the enrollee's condition does not meet criteria for coverage of an Ability Drive eye gaze control system.
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 Ability Drive eye gaze control system have not been met. Therefore, we decided that the Plan does not have to pre-approve an Ability Drive eye gaze control system (K0108) for the enrollee.