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

 
We decided that the Plan does not have to pre-approve an ultrasonic osteogenesis stimulator (E0760). 
 
You asked the Plan to pre-approve an ultrasonic osteogenesis stimulator. 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 an ultrasonic osteogenesis stimulator (E0760) is 
covered when 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 an ultrasonic osteogenesis stimulator. 
Our reviewer says that the services are not medically necessary. Our physician reviewer found there was no 
provided recent x-rays showing non-healing, but only the ones from April 2023. As clinically, the enrollee 
appears to be healing, there is insufficient support made for the ultrasonic osteogenesis stimulator, and the LCD 
criteria is not met. 
 
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 ultrasonic osteogenesis stimulator have not been met. Therefore, we decided 
that the Plan does not have to pre-approve an ultrasonic osteogenesis stimulator (E0760).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for implantation of acellular dermal matrix (code 15777) 
provided on August 19, 2022. 
 
You asked the Plan to pay for implantation of acellular dermal matrix. You say that implantation of acellular 
dermal matrix was medically necessary. The Plan denied your request. The Plan says a review of the current 
medical literature indicates the use of acellular dermal matrices for breast reconstruction have been associated 
with higher complication rates and have not been associated with improved outcomes. Additionally, use of 
acellular dermal matrices for breast reconstruction is not approved by the Food and Drug Administration and is 
considered to be an "off-label" use. 
 
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 pay for implantation of acellular dermal matrix. Our 
reviewer says that the requested implantation of acellular dermal matrix is not considered medically reasonable 
and necessary in this case. Our physician reviewer found that in this case, the record indicates that the enrollee 
has breast cancer and underwent tissue expander placement including the requested service. There is 
insufficient literature to support the safety and efficacy, as defined by Medicare rules, of the requested service. 
The record provided does not establish the medical necessity and reasonableness, as defined by Medicare rules, 
of the requested service. The elements of the coverage criteria are not satisfied. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of implantation of acellular dermal matrix have not been met. Therefore, we 
decided that the Plan does not have to pay for implantation of acellular dermal matrix (code 15777) provided 
on August 19, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on June 12, 2020. 
 
You asked the Plan to pay for an office visit. You say that you requested for reconsideration. The Plan denied 
your request. The Plan says a Medicare Health Plan must receive claims within 12 months from the date of 
service. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for an office visit was not filed until June 12, 2020. This means that more than 
one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the 
Plan does not have to pay for an office visit provided on June 12, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Cala Trio nerve stimulator device (K1018, K1019). 
 
You asked the Plan to pre-approve a Cala Trio nerve stimulator. You say that the requested item is a medical 
necessity for the enrollee. The Plan denied your request. The Plan says the requested item is not a covered 
benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that electric nerve stimulation employed to treat 
motor function disorders cannot be considered reasonable and necessary. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a Cala Trio nerve stimulator have not been met. Specifically, the request is for electric nerve 
stimulation to treat a motor function disorder. Therefore, we decided that the Plan does not have to pre-approve 
a Cala Trio nerve stimulator device (K1018, K1019).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve the IRF care. You say that the IRF care is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the enrollee does not meet the criteria for IRF care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and 
an intensive rehabilitation therapy program. There is not a reasonable expectation that the enrollee will be able 
to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF as 
medically necessary care can be provided in a different level of care. 
 
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 IRF care have not been met. Therefore, we decided that the Plan does not 
have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure. 
 
You asked the Plan to pre-approve an Intracept procedure. You say that the enrollee suffers from chronic back 
pain. The Plan denied your request. The Plan says this procedure has been correctly denied. 
 
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 Intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the magnetic resonance imaging (MRI) does not describe modic changes. Also, the 
cause of back pain is not clear. 
 
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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Intracept procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on April 26, 2023, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for an office visit. You say that you want this claim to be processed correctly. The 
Plan denied your request. The Plan says the services are not authorized because Arizona Pain Specialist is a 
non-network provider who does not work with the member's health Plan. 
 
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 an office visit provided on April 26, 2023, by an 
out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the grab bars and related services provided from February 
15, 2023, to March 11, 2023. 
 
You asked the Plan to pay for the services provided. You say that the grab bars are a necessity to keep your 
balance. The Plan denied your request. The Plan says the services were not primarily medical in nature. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
 
 
 The items at issue in this appeal does not serve a purpose that is primarily medical in nature. The services are 
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 pay for the grab bars and related services provided from February 15, 
2023, to March 11, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an implant supported to denture (D6111) and a semi-
precision attachment (D6192) for tooth #21 and #28 provided on December 20, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were told you are able to get partial 
dentures every 5 years. The Plan denied your request. The Plan says the denial of payment for these services is 
correct, because the implant supported to denture and a semi-precision attachment 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 Plans coverage rules apply in this case. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for an 
implant supported to denture (D6111) and a semi-precision attachment (D6192) for tooth #21 and #28 provided 
on December 20, 2022.
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 medical necessity coverage criteria is not met as the pain is multifactorial. 
 
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 the enrollee does not meet criteria for coverage. Our physician reviewer found detailed documentation is 
not evident regarding an acute or subacute fracture at the T11-12 level. The compression fracture of T12 was 
noted on the April 19, 2023, magnetic resonance imaging (MRI). Moreover, there is MRI 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: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for a duplex scan (procedure code 93970) rendered on November 2, 2022. 
 
You asked the Plan to pay for the scan. You say that this should be paid for. The Plan denied your request. The 
Plan says that Current Procedural Terminology (CPT) code 93970-26 (1 Unit) remains not supported. 
 
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 93970 is "Duplex scan of extremity veins including responses to compression and other maneuvers; 
complete bilateral study." 
 
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 scan. Our reviewer says that the services at issue in this 
case were supported by the medical records. Our reviewer found that a review of the records showed a 
complete report of bilateral lower extremity venous ultrasound - CPT 93970 - on November 2, 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 scan have been met. Therefore, we decided that the Plan has to pay for a 
duplex scan (procedure code 93970) rendered on November 2, 2022.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent hospital care (99233) provided on April 8, 2023, 
and April 9, 2023. 
 
You asked the Plan to pay for subsequent hospital care (99233). You say that the attached documentation 
supports the level of care billed. The Plan denied your request. The Plan says the records do not support a high 
level of medical decision making or the total time. 
 
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 99233 is subsequent hospital inpatient or observation 
care, per day, for the evaluation and management of a patient, which requires a medically appropriate history 
and/or examination and high level of medical decision making. When using total time on the date of the 
encounter for code selection, 50 minutes must be met or exceeded. 
 
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 99233. Our reviewer says that procedure code 99233 is not 
supported for either date of service. Our reviewer found that the documentation does not support a 
comprehensive history, medical decision making of high complexity, or at least 50 minutes of care spent. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 99233 have not been met. Therefore, we decided that the Plan does not have to 
pay for subsequent hospital care (99233) provided on April 8, 2023, and April 9, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for two additional units of procedure code 88374 rendered on 
July 1, 2022. 
 You asked the Plan to pay for the services. You say that the laboratory report shows the stain performed and 
validates the number of units billed. The Plan denied your request. The Plan says the claim was processed 
correctly with the maximum units allowed for CPT 88374. 
 
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 88374 is "Morphometric analysis, in situ hybridization 
(quantitative or semi-quantitative), using computer-assisted technology, per specimen; each multiplex probe 
stain procedure." 
 
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 states that the 
additional units were performed but does not clearly state why these additional services are medically 
necessary and reasonable. 
 
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 two additional units of procedure code 88374 rendered on July 1, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the DecisionDx-SCC test (0315U) provided on March 22, 
2023. 
 
You asked the Plan to pay for the DecisionDx-SCC test. You say that this testing is medically necessary. The 
Plan denied your request. The Plan says this testing is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that molecular diagnostic laboratory tests are subject 
to the MolDX application, assessment, and approval process. 
 
We looked at the file and Medicare rules. This test is listed in the DEX database as not covered. Based on this information, we decided that Medicare rules for coverage of the DecisionDx-SCC test have not been met. 
Therefore, we decided that the Plan does not have to pay for the DecisionDx-SCC test (0315U) provided on 
March 22, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the knee orthosis and suspension sleeve rendered on August 
25, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says there is no valid proof of delivery. 
 
The Plan must follow Medicare rules. The rules say that a supplier must have an order from the treating 
physician before dispensing any durable medical equipment (DME) item to a beneficiary. 
 
We looked at the file and Medicare rules. There is no valid physician order for the DME. 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 pay for the knee orthosis and suspension sleeve rendered on August 25, 
2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve kyphoplasty (22514, 22515). 
 
You asked the Plan to pre-approve kyphoplasty. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not medically necessary because the records show acute compression fracture at 
L3 and L4 there is documentation of retropulsion at L3 and L4 with severe right lateral recess stenosis and 
canal stenosis at L3-4 which is a contraindication to the 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 kyphoplasty. Our reviewer says that the 
enrollee does not meet criteria for coverage. Our physician reviewer found there is bone retropulsion which is a 
contraindication to kyphoplasty. 
 
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).
Appeal type: Testing
Decision: Partially Favorable

 
We decided that the Plan has to pay for 93880. We decided that the Plan does not have to pay for 93040.  
 
You asked the Plan to pay for procedure codes 93040 and 93880 rendered on February 13, 2023.. You say that 
this should be paid for. The Plan says that the records do not support the services billed. 
 
We decided that the Plan has to pay for 93880.  
 
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 definition of CPT 93880 is "Duplex scan of 
extracranial arteries; complete bilateral study." 
 
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 for CPT 93880. Our reviewer says that there is 
documentation including technique, findings, and impression of CPT 93880 - extracranial duplex ultrasound on 
February 13, 2023. This is included in the encounter notes of the same date. 
 
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 been met. Therefore, we decided that the Plan has to pay for 
93880.  
 
We also decided that the Plan does not have to pay for 93040. 
 
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 definition of CPT 93040 is "Rhythm 
electrocardiogram (ECG), 1-3 leads; with interpretation and report." 
 
In this case, we have confirmed that code 93040 is a column II code to column I code 93306. 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 93040. 
 
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.