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

 
We decided that the Plan does not have to pre-approve 9 months continued use of home ventilator, any type, 
used with non-invasive interface (E0466). 
 
You asked the Plan to pre-approve a ventilator. You say that please see attached clinics, prescription and 
compliance report this the enrollee's non-invasive ventilator. The Plan denied your request. The Plan says under 
Medicare, the request for continued use of non-invasive ventilator (NIV) is not medically reasonable and 
necessary.  
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a ventilator. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found continuation of the home ventilator is not medically necessary. This enrollee has COPD and 
obstructive sleep apnea and has had a home ventilator since 2022. Arterial blood gases done while stable 
document chronic carbon dioxide (CO2) retention. There is no documentation that BiPAP with average volume 
assured pressure support (AVAPS) has been tried and failed as an outpatient. Medicare does not cover a home 
ventilator when used at settings that can be provided with BiPAP. The current device has been approved for 3 
months which allows time to transition to BiPAP.  
 
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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve 9 months continued use of home ventilator, any type, used with non-invasive interface 
(E0466).
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 this 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 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 computer assisted 
total knee arthroplasty has not been shown to be better than conventional total knee arthroplasty 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 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve electronic connection between wheelchair controller and 
2 or more power seating system motors (E2311). 
 
You asked the Plan to pre-approve the upgraded electronic. You say that you are requesting consideration of 
this K0838 and all components to meet the enrollee's medical functional and mobility needs throughout the day 
in the home. The Plan denied your request. The Plan says this request is not medically necessary because the 
approved power options come with their own switches. 
 
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 electronic. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the documentation does not support that it is medically necessary to control the 
requested power options through the joystick (drive interface). The enrollee's upper extremity strength and 
functional ability as evidenced by being independent for feeding should be sufficient to control any power 
options through their own switches.  
 
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 electronic have not been met. Therefore, we decided that the Plan 
does not have to pre-approve electronic connection between wheelchair controller and 2 or more power seating 
system motors (E2311).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services coded as 85025, 83036, 80053, 
86803, 87389, 84443, 82607 and 82745 provided January 17, 2023. 
 
You asked the Plan to pay for the laboratory service. You say that please review the attached medical records 
supporting medical necessity and reprocess the claim for payment. The Plan denied your request. The Plan says 
screening services without documentation of medical indication from the treating provider is not a benefit.  
 
The Plan must follow Medicare rules. The rules explicitly say that screening tests, with the exception of the 
few tests listed in the Medicare rules section, 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 the laboratory service. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee presented for their annual physical had labs sent. The documentation 
does not outline how the labs satisfy any of the LCD criteria. 
 
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 laboratory service have not been met. Therefore, we decided that the Plan 
does not have to pay for the laboratory services coded as 85025, 83036, 80053, 86803, 87389, 84443, 82607 
and 82745 provided January 17, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on December 22, 2022, billed 
with codes 81162, 81201, 81272, 81292, 81295, 81298, 81307, 81317, 81321, 81334 and 81351. 
 
You asked the Plan to pay for the genetic testing billed. You say that this testing was medically necessary and 
is supported in the medical records. The Plan denied your request. The Plan says panel testing should be billed 
using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
December 22, 2022, billed with codes 81162, 81201, 81272, 81292, 81295, 81298, 81307, 81317, 81321, 
81334 and 81351.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for Transcutaneous Electrical Never Stimulator (TENS) unit and supplies.
You asked the Plan to pay for this claim. You say that this claim should be paid. The Plan denied your request. The Plan says the Medicare billing criteria were not met. Maximus overturned the Plans denial. The Plan requested a reopen and noted that the provider has been submitting claims for A4595 Electrical stimulator supplies, 2 lead, per month since 03/15/2022. Per LCD ID L33802 for all DMEPOS items that are provided on a recurring basis, suppliers are required to have contact with the beneficiary or caregiver/designee prior to dispensing a new supply of items. Suppliers must not deliver refills without a refill request from a beneficiary. Items delivered without a valid, documented refill request will be denied as not reasonable and necessary. Suppliers must not dispense a quantity of supplies exceeding a beneficiary's expected utilization. Suppliers must stay attuned to changed or atypical utilization patterns on the part of their clients. Suppliers must verify with the treating practitioners that any changed or atypical utilization is warranted. Regardless of utilization, a supplier must not dispense more than a three (3) - month quantity at a time. The provider did not submit any evidence that they have been contacting the member before shipping additional supplies. A 4-lead TENS unit may be used with either 2 leads or 4 leads, depending on the characteristics of the beneficiary's pain. If it is ordered for use with 4 leads, the medical record must document why 2 leads are insufficient to meet the beneficiary's needs. Supplies Separate allowance will be made for replacement supplies when they are reasonable and necessary and are used with a covered TENS. Usual maximum utilization is: - 2 TENS leads - a maximum of one unit of A4595 per month. 4 TENS leads - a maximum of two units of A4595 per month It is also noted that the provider has billed 6 units which exceeds the maximum as described above.
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 A4595 is Electrical stimulator supplies, 2 lead, per month, (e.g., TENS, NMES). We find that CPT code A4595 is not supported in the medical record. Based on this information, we decided that Medicare rules for coverage of this claim have not been met. Therefore, we decided that the Plan does not have to pay for Transcutaneous Electrical Never Stimulator (TENS) unit and supplies.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve white glass with high gold content crown tooth 2 and 3 
(D2750). 
 
You asked the Plan to pre-approve white glass with high gold content crown. You say that this is medically 
necessary. The Plan denied your request. The Plan says this is denied due to your tooth must have a lot of tooth 
missing from a cavity or have a lot of damage from being broken and it can no longer be fixed with a filling. 
For front teeth, half of the biting part of the tooth needs to be missing. For the back teeth in front of your 
molars, you need to have damage on three sides of the tooth and one of the biting parts of the tooth. For the 
back molars, you need to have damage on four sides of the tooth and two of the biting part of the tooth. The x-
rays your dentist sent show your tooth does not have the damage needed for a crown to be needed to fix your 
tooth.   

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. The Plan covers white glass 
with high gold content crown when the services are medically necessary and reasonable.  
 
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 white glass with high gold content 
crown. Our reviewer says that the service is not medically necessary. Our physician reviewer found based off 
of the clinical records submitted, I am unable to make a determination that D2750-crowns for teeth numbers 2 
and 3 are medically reasonable and necessary. There were no clinical notes or photos included and the x-rays 
that were submitted are undiagnostic. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of white glass with high gold content crown have not been met. Therefore, we 
decided that the Plan does not have to pre-approve white glass with high gold content crown tooth 2 and 3 
(D2750).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit coded 99204 for date of service January 11, 
2023. 
 
You asked the Plan to pay for the office visit coded 99204. You say that you disagree with the Plan's denial. 
The Plan denied your request. The Plan says the services billed are 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 99204 is office or other outpatient visit for the evaluation 
and management of a new patient, which requires a medically appropriate history and/or examination and 
moderate level of medical decision making. When using time for code selection, 45-59 minutes of total time is 
spent on the date of the encounter. 
 
We find that CPT code 99204 is not supported in the medical record. Specifically, the documentation does not 
include the time spent on this service. Without this documentation, the code billed is not supported. Based on 
this information, we decided that Medicare rules for coverage of the office visit coded 99204 have not been 
met. Therefore, we decided that the Plan does not have to pay for the office visit coded 99204 for date of 
service January 11, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on February 3, 2023, billed with 
codes 81209, 81223, 81241, 81250, 81279, 81305, 81307, 81311, 81320, 81321, 81334, 81339 and 81345. 
 
You asked the Plan to pay for the genetic testing billed. You say that this test was medically necessary and is 
supported in the medical record. The Plan denied your request. The Plan says panel testing should be billed 
using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
February 3, 2023, billed with codes 81209, 81223, 81241, 81250, 81279, 81305, 81307, 81311, 81320, 81321, 
81334, 81339 and 81345.
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 11, 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 11, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an addition, endoskeletal, knee-shin system, stance 
flexion feature, adjustable (L5845), an all-lower extremity prosthesis, energy storing foot (L5976), an all 
endoskeletal lower extremity prosthesis, axial rotation unit, with or without adjustability (L5984), a lower 
extremity prosthesis, not otherwise specified (L5999). 
 
You asked the Plan to pre-approve prosthetics. You say that the enrollee is a recent amputee and cannot move 
without prosthetics. The Plan denied your request. The Plan says the request for a K3 prosthesis exceeds the 
enrollee's need and does not meet Medicare criteria as reasonable and necessary. The requested L5999 Hi-Fi 
socket is unbundled and does not meet Medicare criteria as reasonable and 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 prosthetics. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee has impaired blood flow in her contralateral leg. She has chronic obstructive 
pulmonary disease (COPD) and chronic respiratory failure. She previously walked with a cane and has 
undergone a transfemoral amputation. She is a K2 ambulator and the specific medical necessity for an 
advanced ankle and foot system has not been supplied per LCD 33787. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of prosthetics have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an addition, endoskeletal, knee-shin system, stance flexion feature, adjustable (L5845), an 
all-lower extremity prosthesis, energy storing foot (L5976), an all endoskeletal lower extremity prosthesis, 
axial rotation unit, with or without adjustability (L5984), a lower extremity prosthesis, not otherwise specified 
(L5999).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bone marrow aspirate (20939). 
 
You asked the Plan to pre-approve a bone marrow aspirate. You say that this is medically necessary. The Plan 
denied your request. The Plan says the clinical value and effectiveness of bone marrow aspirate in the setting of 
spinal fusion surgery have 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 bone marrow aspirate. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that bone marrow aspirate is experimental in spine surgery. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a bone marrow aspirate have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a bone marrow aspirate (20939).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99152 billed for date of service December 
29, 2022. 
 
You asked the Plan to pay for procedure code 99152. You say that you have billed the services at issue 
correctly. The Plan denied your request. The Plan says rules for payment have not been met. 
 
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 99152 is: Moderate sedation services provided by the 
same physician or other qualified health care professional performing the diagnostic or therapeutic service that 
the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of 
the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age 
5 years or older. 
 
We find that CPT code 99152 is not supported in the medical record. Specifically, the provided medical records 
do not support the presence of an independent trained observer to assist in the monitoring of the enrollee's level 
of consciousness and physiological status. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99152 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99152 billed for date of service December 29, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve kyphoplasty at T6 (22515). 
 
You asked the Plan to pre-approve kyphoplasty at T6. You say that the services are necessary. The Plan denied 
your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not 
been met. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve kyphoplasty at T6. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is limited published, large-scale, long-term peer-reviewed literature that shows 
this request to be an effective and/or safe treatment for the noted pathology. The beneficial effects of this 
procedure have not been proven over sham procedures. There are other plausible causes of her pain evident. No compelling rationale is presented, or extenuating circumstances noted to support the medical necessity of this 
request as an exception. Therefore, the requested kyphoplasty at T6 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 kyphoplasty at T6 have not been met. Therefore, we decided that the Plan does 
not have to pre-approve kyphoplasty at T6 (22515).