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

 
We decided that the Plan does not have to pre-approve the L3 Kyphoplasty (22514). 
 
You asked the Plan to pre-approve the service. You say that the service is medically necessary. The Plan 
denied your request. The Plan says the service is not medically necessary. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the service. Our physician reviewer 
found detailed documentation is not evident regarding worsening pain. The enrollee is not documented to have 
been hospitalized. There is no indication of a progression of the body height loss or a severe impact on the 
enrollee's daily activities. Moreover, there is magnetic resonance imaging (MRI) corroboration of retropulsion 
and multiple plausible other causes of the lumbar pain. Therefore, the enrollee does not meet the coverage 
criteria detailed in the LCD. 
 
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 service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the L3 Kyphoplasty (22514).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve laboratory services to be provided by an out-of-network 
(OON) provider.  
 
You asked the Plan to pre-approve laboratory services. You say that your Provider and his staff chose the 
provider therefore should be the party liable for payment. 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 
laboratory services to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 97164 billed for date of service November 
21, 2022. 
 
You asked the Plan to pay for procedure code 97164. You say that authorization was applied for, and the claim 
wrongly denied. The Plan denied your request. The Plan says payment for code 97164 is bundled into payment 
for code 97032. 
 
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 97164 
is a column II code to column I code 97032. 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 97164 billed for date of service November 21, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a crown (D2751) provided on February 8, 
2023. 
 
You asked the Plan to waive the coinsurance for the dental services. You say that the services should be 
covered as you disagree with the charges.  The Plan denied your request. The Plan says the cost-sharing applied 
correctly based on the services provided. 
 
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. 
 
You have been asked to pay a 20% coinsurance for a crown. This item/service falls within the endodontic 
dental benefit category. This means that you have been asked to pay the correct amount based on your contract 
with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to waive the coinsurance for a crown (D2751) provided on 
February 8, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve podiatry services to be provided by an out-of-network 
(OON) provider.  
 
You asked the Plan to pre-approve podiatry services. You say that you feel comfortable with the Provider. 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 
podiatry services to be provided by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Partially Favorable

We decided that the Plan has to pay for procedure code 95938. We decided that the Plan does not have to pay for procedure codes 95999, 95822, and 95870.

You asked the Plan to pay for procedure codes 95999, 95938, 95822, and 95870. You say that the claim was billed correctly. The Plan says that procedure codes 95999, 95938, 95822, and 95870 are not supported.

We decided that the Plan has to pay for procedure code 95938.

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 procedure codes at issue. Our reviewer says that procedure code 95938 meets the criteria for coverage. Our physician reviewer found the procedure report includes documentation of a short-latency somatosensory evoked potential study in the upper and lower extremities, which in this case are the ulnar nerve and posterior tibial. Therefore, we decided that the Plan has to pay for procedure code 95938.

We also decided that the Plan does not have to pay for procedure codes 95999, 95822, and 95870.

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 95999, 95822, and 95870. Our reviewer says that these codes do not meet the criteria for coverage. Our physician reviewer found that Train-of-Four testing is documented in the procedure report; however, this procedure does not have an assigned procedure code. This procedure is included in the primary neuromonitoring service and would not be reported separately. The procedure report describes a neuromonitoring service provided for a transforaminal lumbar interbody fusion, but there is a more appropriate neuromonitoring code that would be reported for the service provided. Procedure code 95870 was billed twice with 2 units, but billing 4 units for this procedure code cannot be verified. Therefore, we decided that the Plan does not have to pay for procedure codes 95999, 95822, and 95870.

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 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 wheelchair accessories. You say that the enrollee needs the requested 
electronics to operate the power wheelchair. The Plan denied your request. The Plan says although there are 
three approved power options on this wheelchair (tilt, recline and elevating leg rests), there is not a medical 
need to control these power options through the joystick. Member is independent with self-feeding. 4/5 
bilateral upper limb strength. 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 enrollee has a spinal cord injury and major functional impairment. He is able to 
feed himself. Per Medicare guidelines, the enrollee has adequate strength to manage standard power drives. 
The expandable controller is not medically necessary to meet the enrollee's 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 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) and an expandable controller (E2377).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the specialist office visits, and Part B drugs 
provided from July 7, 2022, to November 21, 2022. 
 
 
You asked the Plan to waive the cost share for the office visits and Part B drugs. You say that you did not have 
to pay for these services last year. The Plan denied your request. The Plan says this cost sharing was charged 
correctly. 

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for Medicare Part B drugs. The Plan contract also says that enrollees must pay a $25 copayment 
for each specialist office visit. 
 
You have been asked to pay 20% coinsurance for the Part B drugs provided on July 7, 2022, and September 15, 
2022, to November 21, 2022. These items/services fall within the Medicare Part B drugs benefit category.  
 
You have also been asked to pay a $25 copayment for each specialist office visit provided from July 7, 2022, to 
November 21, 2022. A specialist office visit falls within the physician/practitioner services benefit category. 
This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to waive the cost share for the specialist office visits, and Part B drugs provided from 
July 7, 2022, to November 21, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve nine months of continued use of a non-invasive 
ventilator (NIV) (E0466). 
 
You asked the Plan to pre-approve continued use of a non-invasive ventilator. You say that the enrollee 
currently has a device and without this approval, it will be taken away and he will die. The device is medically 
necessary. The Plan denied your request. The Plan says the request for continued use of NIV is not medically 
reasonable and necessary. There is no supporting documentation that this NIV is being used as intended. 
 
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 continued use of a non-invasive 
ventilator. Our reviewer says that the service is not medically necessary. Our physician reviewer found the 
enrollee has a diagnosis of chronic respiratory failure consequent to chronic obstructive pulmonary disease. 
Provided records document that the home ventilator is being requested for use in average volume assured 
pressure support (AVAPS) mode which is a modality which could be provided by a bilevel positive airway 
pressure (BiPAP) device with AVAPS and a back-up rate. Provided records do not document trial and failure 
of a BiPAP device with AVAPS and a back-up rate. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continued use of a non-invasive ventilator have not been met. Therefore, we 
decided that the Plan does not have to pre-approve nine months of continued use of a non-invasive ventilator 
(NIV) (E0466).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided on 
October 4, 2022. 
 
You asked the Plan to pay for the dental service. You say that you are appealing the denied dental services 
because you were not aware that deep cleaning was only covered every 24 months. 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 the date of service of September 24, 
2020. Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) 
provided on October 4, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve these items a tracheostomy shower protector (A7523). 
 
You asked the Plan to pre-approve these items a tracheostomy shower protector. You say that the enrollee 
requires these supplies to manage his airway. The Plan denied your request. The Plan says the requested item is 
considered a convenience item and is not covered by Medicare. 
 
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 these items a tracheostomy shower protector (A7523).
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 wheelchair accessories. You say that the enrollee has a history of multiple 
pressure sores and is at risk for further development. She requires the need to tilt her chair for pressure relief, 
recline her chair to relieve spasms, catheter and ostomy management and power elevating legs to elevate her 
legs for improved circulation. Power elevating legs will also assist with addressing the spastic tone in her legs 
so she can extend those muscles and relieve the spasms for contracture prevention and pain relief. A single 
power chair with just tilting will not meet her medical needs. The Plan denied your request. The Plan says 
although there are three requested power options (tilt, recline and elevating leg rests), there is not a medical 
need to control these power options through the joystick. 
 
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 enrollee is non ambulatory and has bilateral upper extremity strength of 3/5. Per 
Medicare guidelines, the enrollee has adequate strength to manage standard power drives. The expandable 
controller is not medically necessary to meet the enrollee's 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 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), and an expandable controller (E2377).
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the urinary tract infection (UTI) antibiotic resistance polymerase chain 
reaction (PCR) testing provided on January 24, 2023. 
 
You asked the Plan to pay for the UTI antibiotic resistance PCR testing. You say that the enrollee was sent to 
the laboratory by their provider for medically necessary services. The Plan denied your request. The Plan says 
that this testing was not medically necessary. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the Plan unless notice is provided that the services will not be covered. 
The plan follows these rules. 
 
The enrollee was referred for the UTI antibiotic resistance PCR testing by a contract provider. The file does not 
show that the plan provided notice that the UTI antibiotic resistance PCR testing would not be covered. Under 
Medicare rules, this means the UTI antibiotic resistance PCR testing is considered approved by the Plan. 
Therefore, we decided that the Plan has to pay for the urinary tract infection (UTI) antibiotic resistance 
polymerase chain reaction (PCR) testing provided on January 24, 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone marrow aspirate (20939). 
 
You asked the Plan to pre-approve bone marrow aspirate. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve bone marrow aspirate. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found bone marrow aspirate remains experimental in spine surgery. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of bone marrow aspirate have not been met. Therefore, we decided that the Plan 
does not have to pre-approve bone marrow aspirate (20939).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the bone marrow aspirate (20939) and the Medtronic 
Infuse bone morphogenetic protein (BMP) allograft (20930). 
 
You asked the Plan to pre-approve the services. You say that the services are medically necessary. 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 the services. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the bone marrow aspirate is experimental in spine surgery and BMP is not Food and Drug Administration (FDA) approved for posterior spine use. Iliac crest autograft is the gold standard. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the bone marrow aspirate (20939) and the Medtronic Infuse bone morphogenetic protein 
(BMP) allograft (20930).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (85027, P9603, 80048) provided on 
December 28, 2022. You asked the Plan to pay for laboratory services. 

You say that these services were not bundled and should be 
paid. The Plan denied your request. The Plan says the payment for these services has already been 
provided/included in the payment to the skilled nursing facility. 
 
The Plan must follow Medicare rules. Medicare rules say that generally the skilled nursing facility (SNF) bills 
the A/B Medicare Appeals Contractor (MAC) for laboratory services furnished to a Medicare beneficiary in a 
Part A covered stay. These services are included in the SNF Prospective Payment System (PPS) payment.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of laboratory services have not been met. Specifically, these services were provided to an enrollee in 
a covered Part A SNF stay and were billed by the SNF facility. Therefore, we decided that the Plan does not 
have to pay for laboratory services (85027, P9603, 80048) provided on December 28, 2022.