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

 
We decided that the Plan does not have to pre-approve L1 kyphoplasty and an L5 vertebroplasty (22511, 
22514). 
 
You asked the Plan to pre-approve L1 kyphoplasty and an L5 vertebroplasty. 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 percutaneous vertebroplasty and percutaneous 
vertebral augmentation (PVA or Kyphoplasty) procedures will be considered medically reasonable and 
necessary for certain indications. 
 
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 and an L5 
vertebroplasty. Our reviewer says that the services are not medically necessary. Our physician reviewer found 
there is no trial of fracture bracing. More conservative measures needed. 
 
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 and an L5 vertebroplasty have not been met. Therefore, we 
decided that the Plan does not have to pre-approve L1 kyphoplasty and an L5 vertebroplasty (22511, 22514).
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 April 29, 
2022. 
 
You asked the Plan to pay for procedure code 99100. You say that you have submitted medical records to 
support payment. 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 April 29, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sinus augmentation (D7951). 
 
You asked the Plan to pre-approve sinus augmentation. You say that this should be covered. The Plan denied 
your request. The Plan says this is not a covered service. 
 
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 pre-approve sinus 
augmentation (D7951).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the VivAer procedure (30469). 
 
You asked the Plan to pre-approve the VivAer procedure. You say that this is medically necessary. The Plan 
denied your request. The Plan says medical studies haven't proven this service/item is helpful. 
 
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 VivAer procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is insufficient evidence in the medical literature demonstrating longer-term 
beneficial results of intranasal radiofrequency ablation. 
 
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 VivAer procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the VivAer procedure (30469).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code G0452 billed for date of service September 
9, 2022. 
 
You asked the Plan to pay for procedure code G0452. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says payment for code G0452 is bundled into payment for codes 81455, 
81479, and 81301. 
 
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 G0452 
is a column II code to column I codes 81455, 81479, and 81301. 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 G0452 billed for date of 
service September 9, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve guided tissue regeneration (D7956) and surgical 
placement of implant body (D6010). 
 
You asked the Plan to pre-approve the dental services. You say that this should be covered. The Plan denied 
your request. The Plan says your benefit for the surgical placement of implant body has already been exhausted 
and guided tissue regeneration is not a covered benefit. 
 
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 surgical placement of implant body was exhausted and guided tissue regeneration is 
not a covered benefit. Therefore, we decided that the Plan does not have to pre-approve guided tissue 
regeneration (D7956), surgical placement of implant body (D6010), surgical access to an implant body 
(D6011) and alveoloplasty in conjunction with extractions (D7311).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the upgraded electronics (E2311, E2313, E2377).  
 
You asked the Plan to pre-approve the upgraded electronics. You say that you are requesting reconsideration of 
the denied authorization. The Plan denied your request. The Plan says the upgraded electronics 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 upgraded electronics. 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. The upgraded electronics are 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 the upgraded electronics have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the upgraded electronics (E2311, E2313, E2377).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric care from June 11, 2023, forward. 
 
You asked the Plan to pre-approve inpatient psychiatric care from June 11, 2023, forward. You say that the 
services at issue were medically necessary. The Plan denied your request. The Plan says the services at issue 
were not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient psychiatric care from June 11, 
2023, forward. Our reviewer says that the enrollee does not meet the criteria for treatment in an acute inpatient 
mental health treatment beyond the date in question of June 11, 2023, forward. Our physician reviewer found 
the enrollee is noted to be in no psychiatric distress and is eating and sleeping adequately. The enrollee is 
complaint with medications. The progress notes do not indicate that the enrollee has been aggressive with peers 
or staff on the unit or has had any recent attempt to harm herself during the disputed period. As of the last 
covered day, there is no indication in the available medical records that the enrollees psychiatric symptoms 
could not be managed on a less restrictive basis. As of the last covered day the enrollee did not express any 
active suicidal ideation or intent, or any intent to harm themselves or anyone else. The enrollee was not 
exhibiting any other significant symptoms such as mania. The enrollee had no acute psychiatric issues that 
would require continued inpatient care beyond June 11, 2023. The enrollee has chronic symptoms. The 
available medical records do not support that continued inpatient care will change these symptoms or the 
enrollees current condition. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient psychiatric care from June 11, 2023, forward have not been met. 
Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric care from June 11, 2023, 
forward.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the upgraded electronics (E2311, E2313, E2377).  
 
You asked the Plan to pre-approve the upgraded electronics. You say that you are requesting reconsideration of 
the denied authorization. The Plan denied your request. The Plan says the upgraded electronics 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 upgraded electronics. 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 strength in their right upper extremity to manage the 
standard power drive controls. The upgraded electronics are not 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 the upgraded electronics have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the upgraded electronics (E2311, E2313, E2377).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 87900 billed for date of service January 4, 2023. 
 
You asked the Plan to pay for code 87900. You say that this service is covered and was medically necessary. 
The Plan denied your request. The Plan says code 87900 is not supported by the medical record. 
 
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 87900 is infectious agent drug susceptibility phenotype 
prediction using regularly updated genotypic bioinformatics. 

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 code 87900. Our reviewer says that code 87900 is not 
supported by the medical record. Our reviewer found the medical records provided does not include sufficient 
documentation to validate that procedure 87900 was performed on January 4, 2023, therefore this procedure 
cannot be verified. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 87900 have not been met. Therefore, we decided that the Plan does not 
have to pay for code 87900 billed for date of service January 4, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87640 billed for date of service November 
21, 2022. 
 
You asked the Plan to pay for procedure code 87640. You say that this service is supported in the medical 
record. The Plan denied your request. The Plan says the payment for code 87640 is included in the payment for 
code 87641. Although a modifier was used in this case, the records provided do not support that this modifier 
was used appropriately in this case. 
 
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 87641 is a column II code to column I code 87640; however, 87641 
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 87640. Our reviewer says that this service is 
not supported for separate reporting. Our reviewer found the documentation does not support a distinct service 
from CPT 87641, for assays that detect methicillin resistance and identify Staphylococcus aureus using a single 
nucleic acid sequence, use CPT 87641.  Therefore, claim denied correctly as services are unbundled. 
 
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 87640 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 87640 billed for date of service November 21, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable controller, attendant control, harness, 
compact remote joystick, Hook-N-Loop straps, and chest harness interface kit.  
 
You asked the Plan to pre-approve the components. You say that the enrollee was advised it would be more 
cost effective to replace their power wheelchair. You say that the power wheelchair that was received does not 
fit the enrollee appropriately. You also say that the requested modifications are necessary for the enrollee. The 
Plan denied your request. The Plan says the upgraded electronics (expandable controller, harness) are not 
medically necessary as only one power option was requested. The Plan says an attendant control cannot be 
covered if a user-operated control is requested. The Plan says the requested joystick does not match what is 
requested and cannot be approved. The Plan also says the requested chest straps and foot straps are already 
approved. 
 
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 components. Our reviewer says that 
the requested attendant control, is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the provided documentation does not indicate a medical need for the addition of an 
attendant control. The guidelines say that a wheelchair may not have both user operated and attendant control. 
The reviewer found that the enrollee has adequate control to manage standard power drive controls as the 
enrollee manages the tilt control independently. Therefore, the reviewer found that the attendant control is not 
medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the components have not been met. The file shows that a compact remote 
joystick was not a requested component. The file also shows that the Plan has already approved ankle straps 
and toe loops. Therefore, we decided that the Plan does not have to pre-approve an expandable controller, 
attendant control, harness, compact remote joystick, Hook-N-Loop straps, and chest harness interface kit.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eye examination and the refraction provided on March 3, 
2023. 
 
You asked the Plan to pay for the eye examination and the refraction. You say that the services were medically 
necessary. The Plan denied your request. The Plan says services are not covered benefits. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when provided by a network provider. 
 
We looked at the file and the Plan's rules. Specifically, the provider is out-of-network, and the enrollee does not 
have out-of-network benefits for supplemental vision services. Based on this information, we decided that the 
Plan's rules for coverage of the eye examination and the refraction have not been met. Therefore, we decided 
that the Plan does not have to pay for the eye examination and the refraction provided on March 3, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a 2D oral/facial photographic image (D0350) provided on 
October 31, 2022. 
 
You asked the Plan to pay for D0350. You say that you were unaware that there was a limitation for these 
services. The Plan denied your request. The Plan says this claim has been processed correctly/ 
 
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 a 2D 
oral/facial photographic image (D0350) provided on October 31, 2022.
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 IRF care. The Plan denied your request. The Plan says the enrollee does not
meet the Medicare criteria for admission to an Inpatient Rehabilitation Facility.

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 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.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of 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: 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 IRF care. You say that it is medically necessary. The Plan denied your request. The Plan says The plan denied because the enrollee does not meet the requirements for approval.

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 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 was admitted for a patellar fracture after a fall. Medical problems are stable. There are no complex nursing or rehabilitation needs.

The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care.

There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance supplies (A0398, A0394, and A0999) 
provided on November 12, 2022. 
 
You asked the Plan to pay for the ambulance supplies. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that ambulance supplies are considered part of the 
general ambulance service and payment for them is included in the payment rate for the transport. Therefore, 
we decided that the Plan does not have to pay for the ambulance supplies (A0398, A0394, and A0999) 
provided on November 12, 2022.