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

 
We decided that the Plan does not have to pay for the travel allowance for specimen collection provided on 
November 29, 2022, billed with 17 units of code P9603. 
 
You asked the Plan to pay for the travel allowance as billed. You say that this testing should be paid.  The Plan 
denied your request. The Plan says all testing was approved for payment; however, there is not sufficient 
documentation to support the travel allowance billed.   

The Plan must follow Medicare rules. Medicare rules say that payment can be made for travel to obtain a lab 
specimen, but it limited to the mileage from the starting point, to the enrollee, and back to the lab.  
 
We looked at the file and Medicare rules. The records provided do not provide a detailed account of where and 
when travel started and when it ended. As such, we cannot verify the number of units billed. Based on this 
information, we decided that Medicare rules for coverage of the travel allowance as billed have not been met. 
Therefore, we decided that the Plan does not have to pay for the travel allowance for specimen collection 
provided on November 29, 2022, billed with 17 units of code P9603.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 95822 billed for date of service July 6, 2022. 
 
You asked the Plan to pay for procedure code 95822. You say that this service is supported in the medical 
record. The Plan denied your request. The Plan says this code is not supported in the medical record. The 
service provided would be more accurately reported with a different code. 
 
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 95822 is electroencephalogram (EEG); recording in coma 
or sleep only. 
 
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 code 95822. Our reviewer says that this code is 
not supported in the medical record. Our reviewer found in this case, CPT 95822 is inappropriate code to report 
as there is a more appropriate code to report for service provided, which in this case would be EEG during non-
intracranial surgery (e.g., carotid surgery). This procedure denied correctly, as the service was billed 
incorrectly. 
 
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 code 95822 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 95822 billed for date of service July 6, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device provided on January 4, 
2023, by an OON provider.  
 
You asked the Plan to pay for the compression device. You say that you are requesting reconsideration of the 
denied claim. The Plan denied your request. The Plan says this service was not authorized. 
 
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 a pneumatic compression device provided on 
January 4, 2023, by an OON provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 75822 billed for date of service February 16, 
2023. 
 
You asked the Plan to pay for procedure code 75822. You say that this service is supported in the medical 
record. The Plan denied your request. The Plan says this code is not supported for separate payment. 
 
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 75822 is a column II code to column I code 37238; however, 75822 
was billed with a modifier.  
 
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 code 75822. Our reviewer says that this code is 
not supported for separate payment. Our reviewer found the procedure report does not support a distinct 
procedural service as an intervention (which includes radiological services) was performed in same anatomical 
location as the venography. Therefore, modifier -59 cannot be verified and this service would be included in 
code 37238. 
 
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 code 75822 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 75822 billed for date of service February 16, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the unspecified periodontal procedures (D4999) for all 4 
quadrants provided on January 3, 2023. 
 
You asked the Plan to pay for the dental services. You say that the provider said that the Plan would cover the 
dental services. The Plan denied your request. The Plan says the denial of payment for these services is correct, 
because the unspecified periodontal procedures are not covered by the Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
unspecified periodontal procedures (D4999) for all 4 quadrants provided on January 3, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient hospital care. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that this is medically necessary. The 
Plan denied your request. The Plan says there is no documentation provided to support the expectation the 
enrollee will require a greater than 2 midnight stay. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient payment are met in this 
case. Our physician reviewer found the provided documentation did not clearly show the enrollee with an 
unstable condition or high risk for complication to expect the enrollee would require hospital services that 
would likely cross 2 midnights to justify this request. A lower level of care would be more appropriate, and 
admission can be considered based on need during or after 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 acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve acute inpatient hospital care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for  dental services provided on November 8, 2022. 
 
You asked the Plan to pay for  dental services. You say that this should be covered. The Plan denied your 
request. The Plan says the provider has 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  dental 
services provided on November 8, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral-periapical additional radiographic image 
(D0230) provided on February 8, 2023. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says your benefit for the dental service provided 
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 service provided was exhausted on date of service February 8, 2023. Specifically, 
the Plan's contract states that the maximum allowable dental benefit per year is $1,000. The Plan issued 
payment to the dental provider in the amount of $1,000 for the services provided on February 8, 2023. 
Additionally, the Plan's contract states that one intraoral-periapical radiographic image is covered per calendar 
year. On this day, two intraoral-periapical radiographic images were provided, in which one x-ray was paid for 
by the Plan. Therefore, you have exhausted the allowable dental benefit for this calendar year. Therefore, we 
decided that the Plan does not have to pay for the intraoral-periapical additional radiographic image (D0230) 
provided on February 8, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve T12 kyphoplasty (22513). 
 
You asked the Plan to pre-approve T12 kyphoplasty. You say that this is medically necessary. The Plan denied 
your request. The Plan says fracture retropulsion/canal compromise is a relative contraindication for this 
procedure. 
 
The Plan follows Medicare rules. Medicare rules say that kyphoplasty can be 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 T12 kyphoplasty. Our reviewer says 
that you do not meet criteria for coverage. Our physician reviewer found detailed documentation is not evident 
regarding worsening pain. There is no indication of a progression of the body height loss, greater than 25% 
vertebral body height loss, kyphotic deformity, or a severe impact on your daily activities. Moreover, there is 
magnetic resonance imaging corroboration of retropulsion. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of T12 kyphoplasty have not been met. Therefore, we decided that the Plan does 
not have to pre-approve T12 kyphoplasty (22513).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 97010 billed for date of service February 16, 
2023, to February 21, 2023. 
 
You asked the Plan to pay for procedure code 97010. You say that you have submitted supporting 
documentation for reconsideration of the denied code. The Plan denied your request. The Plan says procedure 
code 97010 is considered bundled and 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 procedure code. 
 
We find that procedure code 97010 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 97010 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 97010 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 97010 billed for date of service February 16, 2023, to February 21, 2023.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve an electronic connection device (E2311). 
 
You asked the Plan to pre-approve an electronic connection device. You say that you are requesting 
reconsideration of the denied authorization. The Plan denied your request. The Plan says that this item is not 
medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 an electronic connection device. Our 
reviewer says that the requested items/services are considered medically reasonable and necessary in this case. 
Our physician reviewer found that the enrollee is functionally non-ambulatory and requires a power wheelchair 
for mobility and performing his basic daily activities. He cannot perform pressure relief independently due to 
upper extremity weakness. He has a history of skin breakdown and requires a power wheelchair with power tilt 
for adequate pressure relief and positioning. He requires power elevating leg rests for positioning of his lower 
extremities and lower extremity spasticity. The complexity of his seating and positioning needs necessitates a 
more complex Group 3 power wheelchair base. The electronic connection is necessary to operate the Group 3 
power wheelchair base and the power options via a joystick. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an electronic connection device have been met. Therefore, we decided that the 
Plan has to pre-approve an electronic connection device (E2311).  
 
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 L1 kyphoplasty (22514). 
 
You asked the Plan to pre-approve L1 kyphoplasty. You say that this is medically necessary. The Plan denied 
your request. The Plan says medical necessity coverage criteria is not met as the pain is multifactorial with 
multilevel disc disease. 
 
The Plan follows Medicare rules. Medicare rules say that kyphoplasty can be 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 L1 kyphoplasty. Our reviewer says that 
the enrollee does not meet criteria for coverage. Our physician reviewer found detailed documentation is not 
evident regarding worsening pain. There is no indication of a progression of the body height loss, greater than 
25% vertebral body height loss, kyphotic deformity, or a severe impact on the enrollee's daily activities. 
Moreover, there is magnetic resonance imaging corroboration of retropulsion. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of L1 kyphoplasty have not been met. Therefore, we decided that the Plan does not 
have to pre-approve L1 kyphoplasty (22514).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve maxillary partial denture - cast metal framework with 
resin denture bases (including retentive/clasping materials, rests and teeth) (D5213). 
 
You asked the Plan to pre-approve the dental services. You say that you need to get your dentures; you are 
having issues with eating. 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 Plans coverage rules apply in this case. This benefit includes the 
requested item or service but is limited to complete dentures (upper and lower) or partial dentures (upper and 
lower) (1 upper complete/partial and/or 1 lower complete/partial denture every 5 calendar years, including 
routine post-delivery care) includes necessary extractions to fit dentures (unlimited). 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows you received covered maxillary partial denture - cast metal framework with resin denture bases 
(including retentive/clasping materials, rests and teeth) (D5213) on date of service April 7, 2021. Therefore, 
this benefit has been exhausted. Therefore, we decided that the Plan does not have to pre-approve maxillary 
partial denture - cast metal framework with resin denture bases (including retentive/clasping materials, rests 
and teeth) (D5213).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the transplant related lodging and transportation (S9975) 
provided from February 14, 2023, to March 27, 2023. 
 
 You asked the Plan to pay for the transplant related lodging and transportation. You say that not only did you 
have the closest thing to a lung transplant, but during the first half of your stay, you and the medical team 
thought you were going to have a lung transplant. The Plan denied your request. The Plan says on February 13, 
2023, you were admitted to the hospital via the emergency room. The Plan says once you became admitted to 
the hospital, this was the considered non-transplant services. The Plan also says that any of the additional 
lodging that the caregiver had is not eligible to be reimbursed as your care was not transplant related. 
 
The Plan must follow Medicare rules. Medicare rules say that in any circumstance in which an MA plan 
provides transplant services at a more distant location, the MA plan must provide reasonable accommodations 
for the enrollee and a companion while in the distant location for medical care. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of transplant related lodging and transportation have not been met. Specifically, the transportation and 
accommodations received on the dates of service which remain in dispute were not related to qualifying 
transplant services. The documentation provided shows that you were notified by the hospital that you did not 
qualify for transplant surgery due to a specific type of fungus found in your lungs, and following this 
notification the Plan cannot be held liable for transportation and accommodation charges incurred.  Therefore, 
we decided that the Plan does not have to pay for the transplant related lodging and transportation (S9975) 
provided from February 14, 2023, to March 27, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Stabilink instrumentation for spinal surgery. 
 
You asked the Plan to pre-approve Stabilink. You say that you need this instrumentation for your procedure. 
The Plan denied your request. The Plan says the clinical value and effectiveness of Stabilink in the setting of 
lumbar fusion have not been demonstrated in 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 Stabilink. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found Stabilink instrumentation is experimental in spinal surgery. More research is needed to show its safety and efficacy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Stabilink have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Stabilink instrumentation for spinal surgery.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the advanced imaging services (74177, Q9967, 71260) 
provided on December 19, 2022. 
 
You asked the Plan to pre-approve the advanced imaging services. You say that the service should be covered. 
The Plan denied your request. The Plan says the member would have been responsible for $300.00 copayment 
for Advanced Imaging Services in an outpatient setting. This is more than the cost-sharing under Original 
Medicare. Therefore, the Plan is not required to make a payment. 
 
The Plan must follow Medicare rules. The rules say that Original Medicare pays for the routine costs of 
qualifying clinical trials. Enrollees in a Medicare plan receive the same coverage for qualifying clinical trials as 
people enrolled in Original Medicare. The Plan must cover only the difference between the cost-sharing in 
Original Medicare and the plan cost-sharing for the same services. 
 
In this case, you asked the Plan to pre-approve the advanced imaging services as part of a clinical trial. The 
Plan does not cover routine costs associated with qualifying clinical trials. Therefore, we decided that the Plan 
does not have to pre-approve the advanced imaging services (74177, Q9967, 71260) provided on December 19, 
2022.