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

 
We decided that the Plan does not have to pay for a continuous positive airway pressure (CPAP) device 
provided on February 21, 2023. 
 
You asked the Plan to pay for a continuous positive airway pressure (CPAP) device. You say that the approval 
from your previous insurance should be valid. The Plan denied your request. The Plan says that unauthorized, 
out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for a continuous positive 
airway pressure (CPAP) device provided on February 21, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the dental services. 
 
You asked the Plan to pre-approve the dental services. You say that you would like to request reconsideration 
of the denied authorization. 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. 
 
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 December 14, 2022. 
Therefore, we decided that the Plan does not have to pre-approve the dental services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve posterior segmental instrumentation (e.g., pedicle 
fixation, dual rods with multiple hooks and sublaminar wires); 3 to 6 vertebral segments (22842). 
 
You asked the Plan to pre-approve cervical fusion surgery. You say that you disagree with the denial and are 
requesting reconsideration. The Plan denied your request. The Plan says cervical fusion following prior spinal 
surgery is indicated when at least 12 months from prior surgery has passed. Services considered not medically 
necessary are not covered by Medicare or the Plan. 
 
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 cervical fusion surgery. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found twelve months have not passed since the enrollee's previous c6-7 fusion. More time is 
needed to heal prior to any additional revision 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 cervical fusion surgery have not been met. Therefore, we decided that the Plan 
does not have to pre-approve posterior segmental instrumentation (e.g., pedicle fixation, dual rods with 
multiple hooks and sublaminar wires); 3 to 6 vertebral segments (22842).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home or residence visit for the evaluation and management 
provided on February 21, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for home or residence visit for the evaluation and management. You say that the 
services were medically necessary. The Plan denied your request. The Plan says this 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 home or residence visit for the evaluation and 
management provided on February 21, 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 procedure code 99100 billed for date of service August 31, 
2022. 
 
You asked the Plan to pay for procedure code 99100. You say that you disagree with the denial and have 
submitted medical records for review. The Plan denied your request. The Plan says procedure code 99100 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 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service August 31, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computer-assisted musculoskeletal surgical 
navigational orthopedic procedure (0055T). 
 
You asked the Plan to pre-approve a computer-assisted musculoskeletal surgical navigational orthopedic 
procedure. You say that this is medically necessary. The Plan denied your request. The Plan says the clinical 
value and effectiveness of makoplasty for robotic assistance in the setting of total joint arthroplasty 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 a computer-assisted musculoskeletal 
surgical navigational orthopedic procedure. Our reviewer says that the requested items/services are not 
considered medically reasonable and necessary in this case. Our physician reviewer found there are no large 
volume, long-term/high-quality clinical studies that confirm the clinical benefits (ultimate outcomes of 
functional improvement and pain reduction) of computer-assisted surgery over standard surgical approaches in 
total shoulder arthroplasty. No compelling rationale is presented, or extenuating circumstances noted to support 
the medical necessity of this request as an exception. 
 
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 computer-assisted musculoskeletal surgical navigational orthopedic procedure 
have not been met. Therefore, we decided that the Plan does not have to pre-approve a computer-assisted 
musculoskeletal surgical navigational orthopedic procedure (0055T).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 95999 billed for date of service May 30, 
2022.  
 
You asked the Plan to pay for procedure code 95999. You say that you billed this code to describe Train of 
Four testing and this code should not be bundled. The Plan denied your request. The Plan says the number of 
units billed exceeds the maximum allowed.  
 
The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 95999 is 1. The MAI value for this code is 3. You billed 2 units of this 
code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were 
actually provided, were correctly coded, and were medically necessary. You did not provide any specific 
argument with your appeal indicating why the additional unit of this code was billed. Based on this 
information, we decided that Medicare rules for coverage of procedure code 95999 have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure code 95999 billed for date of service 
May 30, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 97139 and J3490 billed for date of service 
October 7, 2022. 
 
You asked the Plan to pay for the billed services. You say that medical records were provided. The Plan denied 
your request. The Plan says vitamin injections were not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
The multiple drug codes reported on this claim refer to a pre-filled compounded drug/vitamin syringe. The 
rules require that any compounded drug be billed using the not otherwise classified code J7999. As this 
compounded drug was not billed properly, payment cannot be made. Based on this information, we decided 
that Medicare rules for coverage of the billed services have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure codes 97139 and J3490 billed for date of service October 7, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 88368, 88369, and 88377 billed for date of 
service January 16, 2023. 
 
You asked the Plan to pay for procedure codes 88368, 88369, and 88377. You say that you disagree with the 
Plan's denial. The Plan denied your request. The Plan says payment for codes 88368, 88369, and 88377 is 
bundled into payment for code 81455. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. The rules also state that providers may bill 
services with a -59 modifier if the service billed with the modifier indicates a distinct procedural service. 
 
In this case, we have confirmed that codes 88368, 88369, and 88377 are column II codes to column I code 
81455. While these services were billed with modifier -59, the medical records provided do not show that the 
services billed with the -59 modifier are distinct procedural services. 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 codes 
88368, 88369, and 88377 billed for date of service January 16, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home visit provided on August 25, 2022. 
 
You asked the Plan to pay for a home visit. You say that the records show authorization was not needed. The 
Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for a home visit provided on 
August 25, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a transcatheter aortic valve replacement (TAVR) with 
prosthetic valve; percutaneous femoral artery approach (33361). 
 
You asked the Plan to pre-approve TAVR. You say that if the enrollee does not get this surgery he will die. The 
Plan denied your request. The Plan says the request is not medically necessary because the records show the 
enrollee does not have documentation by an interventional cardiologist of his suitability for the procedure. 
 
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 TAVR. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found in this case; the record indicates that the enrollee has symptomatic aortic stenosis. The record 
provided does not include documentation that the enrollee has been evaluated by an interventional cardiologist 
as part of the required heart team. The elements of the coverage criteria are not satisfied.  The requested service 
is not recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of TAVR have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a transcatheter aortic valve replacement (TAVR) with prosthetic valve; percutaneous femoral 
artery approach (33361).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Tempus xT Solid Tumor & Heme Comprehensive 
Genomic Profiling (81455) provided December 3, 2022. 
 
You asked the Plan to pay for the laboratory service. You say that this letter and attached documents support 
the medical necessity of the test requested. The Plan denied your request. The Plan says the Tempus xT NGS 
assay was not reasonable and necessary, in accordance with Medicare's guidelines. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. The diagnosis on the claim, C83.30: Diffuse Large B-Cell 
Lymphoma, Unspecified Site, is not listed as a covered diagnosis per Local Coverage Article Billing and 
Coding: Genomic Sequence Analysis Panels in the Treatment of Solid Organ Neoplasms A56867. The use of 
NGS panel testing for management of Diffuse Large B-Cell Lymphoma, is not an accepted standard of care 
and has not been shown to improve outcomes or significantly change management. The testing is not 
recommended by the National Comprehensive Cancer Network (NCCN) guidelines and is not supported by the 
current medical literature. Based on this information, we decided that Medicare rules for coverage of the 
laboratory service have not been met. Therefore, we decided that the Plan does not have to pay for the Tempus 
xT Solid Tumor & Heme Comprehensive Genomic Profiling (81455) provided December 3, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on September 23, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that your organization does not 
have a contract with the dialysis facility for payment of these lab services. The Plan denied your request. The 
Plan says Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on 
September 23, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 88177-26 billed for date of service October 18, 2022. 
 
You asked the Plan to pay for code 88177-26. You say that you billed these services correctly. The Plan denied 
your request. The Plan says you did not bill this code with an appropriate primary procedure. 
 
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 
88177-26 is an add-on code and has not been billed with an appropriate primary procedure code. Based on the 
claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have 
to pay for code 88177-26 billed for date of service October 18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility care provided on March 13, 
2023. 
 
You asked the Plan to pay for the subsequent nursing facility care. You say that you are requesting 
reconsideration of the denied claim. The Plan denied your request. The Plan says that unauthorized, out-of-
network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the subsequent nursing 
facility care provided on March 13, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an abdominal aortic aneurysm (AAA) screening (76706). 
 You asked the Plan to pay for an AAA screening. You say that the service at issue was a medical necessity for 
the enrollee. The Plan denied your request. The Plan says rules for payment for an AAA screening have not 
been met. 
 
The Plan must follow Medicare rules. The rules say that payment may be made for a one-time ultrasound 
screening for AAA for beneficiaries who meet the criteria listed in the Medicare rules section of this letter. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of an AAA screening have not been met. Specifically, the provided medical records do not address 
the coverage criteria for an AAA screening. Therefore, we decided that the Plan does not have to pay for an 
abdominal aortic aneurysm (AAA) screening (76706).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
January 26, 2023.  
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service January 26, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connector (E2310). 
 
You asked the Plan to pre-approve an electronic connector. You say that you are requesting reconsideration of 
the denied authorization. The Plan denied your request. The Plan says the requested item is not medically 
necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve an electronic connector. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee has adequate upper body strength to manage the standard power 
drive controls. 
 
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 connector have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an electronic connector (E2310).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the apicoectomy (D3410) and the bone graft in conjunction 
with peri-radicular surgery (D3428) provided on November 30, 2022. 
 
You asked the Plan to pay for the apicoectomy (D3410) and the bone graft in conjunction with peri-radicular 
surgery (D3428). You say that there was not a dentist in your area who could complete the dental work. The 
Plan denied your request. The Plan says the services are not covered benefits. 
 
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 apicoectomy (D3410) and the bone 
graft in conjunction with peri-radicular surgery (D3428) are not among those covered under this benefit. 
Therefore, we decided that the Plan does not have to pay for the apicoectomy (D3410) and the bone graft in 
conjunction with peri-radicular surgery (D3428) provided on November 30, 2022.