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

 
We decided that the Plan does not have to pre-approve nine (9) month use of a ventilator (E0466). 
 
You asked the Plan to pre-approve 9-month use of a ventilator. You say that you are requesting reconsideration 
for denied services. The Plan denied your request. The Plan says the request for continued use of a ventilator 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 9-month use of a ventilator. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found the enrollee has 
obstructive sleep apnea, obesity hypoventilation syndrome, pulmonary hypertension, and heart failure with 
preserved ejection fraction (HFpEF). There is no diagnosis of COPD, thoracic restrictive disease, or 
neuromuscular disease. The enrollee was prescribed a home ventilator in June 2021, following a hospitalization 
for acute on chronic hypercarbic respiratory failure. The records do not show that the enrollee has tried and 
failed bilevel positive airway pressure (BiPAP) as an outpatient.  Medicare does not cover a home ventilator for 
the treatment of obesity hypoventilation syndrome, or when used at settings that can be provided with 
BiPAP. The plan has approved the ventilator for an additional 3 months to allow time for 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 9-month use of a ventilator have not been met. Therefore, we decided that the 
Plan does not have to pre-approve nine (9) month use of a ventilator (E0466).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve L3 kyphoplasty (22515).  

You asked the Plan to pre-approve L3 kyphoplasty. 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 L3 kyphoplasty. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found detailed documentation is not evident 
regarding worsening pain. There is no indication of a progression of the body height loss, kyphotic deformity, 
or a severe impact on daily activities. Moreover, there is magnetic resonance Imaging (MRI) corroboration of 
retropulsion and other plausible causes of pain. Therefore, the enrollee does not meet the coverage criteria 
detailed in the LCD. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of L3 kyphoplasty have not been met. Therefore, we decided that the Plan does not 
have to pre-approve L3 kyphoplasty (22515).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connection (E2311), harness (E2313), 
expandable controller (E2377), Q-Logic joystick (K0108), and footplate extension (K0108). 
 
You asked the Plan to pre-approve an electronic connection, harness, expandable controller, Q-Logic joystick, 
and footplate extension. You say that the enrollee requires a group 3 chair due to the neurological condition of 
Left Hemiplegia following cerebral vascular accident (CVA). The Plan denied your request. The Plan says 
although there are three requested power options (tilt, recline and elevating leg rests), there is not a medical 
need to control these power options through the joystick. The Plan says the joystick controller display is 
unbundled and cannot be approved. The Plan also says that the footplate accessories are miscoded. 
 
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 connection, harness, 
expandable controller, Q-Logic joystick, and footplate extension. Our reviewer says that the requested 
items/services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the provided records document that the enrollee has 3 plus out of 5 right upper extremity strength and 
can manage self-feeding and toileting with set-up assistance thus indicating the enrollee has adequate upper 
extremity strength and function to operate the wheelchair's power options with their own switches. The 
requested electrical accessories are not medically necessary as the enrollee does have use of the upper 
extremity and can operate and control the power options using the switches that are included in the basic 
wheelchair. Our reviewer found that a joystick controller display is a component of an expandable controller 
(E2377) which does not meet criteria for approval. The footplate extension does not meet criteria for medically 
reasonable and necessary, as two adjustable angle footplates (K0040 x2) have already been approved. Our 
physician reviewer also found that the records do not document the need for a footplate extension. K0041 
would be the appropriate code if a larger footplate were 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 an electronic connection, harness, expandable controller, Q-Logic joystick, and 
footplate extension have not been met. Therefore, we decided that the Plan does not have to pre-approve an 
electronic connection (E2311), harness (E2313), expandable controller (E2377), Q-Logic joystick (K0108), and 
footplate extension (K0108).
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve crowns (D2740 x2). 
 
You asked the Plan to pre-approve crowns. You say that the services are necessary. The Plan denied your 
request. The Plan says that the benefit limit for the crowns has been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan has failed to provide evidence that crowns were covered within the last 
5 calendar years. Therefore, we decided that the Plan has to pre-approve crowns (D2740 x2).  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Depuy Vivigen allograft (20930). 
 
You asked the Plan to pre-approve a Depuy Vivigen allograft. You say that this is medically necessary. The 
Plan denied your request. The Plan says the clinical value and effectiveness of the Depuy Vivigen allograft in 
the setting of a spine 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 Depuy Vivigen allograft. 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 requested allograft to be an effective and/or safe treatment for the noted pathology. Further 
studies are needed to demonstrate this request has beneficial outcomes compared with conventional treatment. 
There is no compelling rationale 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 Depuy Vivigen allograft have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a Depuy Vivigen allograft (20930).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 97010 billed for date of service March 16, 
2023. 
 
You asked the Plan to pay for procedure code 97010. You say that these services were necessary and are 
supported in the medical record. The Plan denied your request. The Plan says procedure code 97010 is 
considered bundled and not separately payable.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 97010 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 97010 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 97010 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 97010 billed for date of service March 16, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675) provided 
September 20, 2022. 
 
You asked the Plan to pay for a pneumatic compression device. You say that you provided the services to the 
enrollee as per their physician's prescription. The Plan denied your request. The Plan says a PCD coded as 
E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device (E0675) provided September 20, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on December 29, 2022, billed 
with codes 87801 and 87798. 
 
You asked the Plan to pay for the genetic testing billed. You say that you disagree with the Plan's denial. 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 29, 2022, billed with codes 87801 and 87798.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connection (E2311), harness (E2313), and 
expandable controller (E2377). 
 
You asked the Plan to pre-approve an electronic connection, harness, and expandable controller. You say that 
when three or more power seating functions/actuators/motors are provided, one unit of E2311, one unit of 
E2377, and one unit of E2313 are allowed. The Plan denied your request. The Plan says although there are 
three approved power options on this wheelchair (tilt, recline and elevating leg rests), there is not a medical 
need to control these power options through the joystick. 
 
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 connection, harness, and 
expandable controller. 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 multiple sclerosis (MS) 
and is independent with feeding and meal preparation. Our reviewer also found that the enrollee has adequate 
upper body strength to manage standard power drives. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an electronic connection, harness, and expandable controller have not been met. 
Therefore, we decided that the Plan does not have to pre-approve an electronic connection (E2311), harness 
(E2313), and expandable controller (E2377).
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 medical necessity for the denied procedure/services has not been 
established after clinical review and per the peer-reviewed medical 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 bone marrow aspirate is experimental. More research is 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 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code G0452 billed for date of service February 3, 
2023. 
 
You asked the Plan to pay for procedure code G0452. You say that you disagree with the denial. The Plan 
denied your request. The Plan says payment for code G0452 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. In this case, we have confirmed that code G0452 
is a column II code to column I code 81455. 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 February 3, 
2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the general health panel (80050) provided April 18, 2023. 
 
You asked the Plan to pay for the laboratory service. You say that you are appealing the denial of the claim. 
The Plan denied your request. The Plan says this service is not payable under Medicare. 
 
The Plan must follow Medicare rules. The rules say that code 80050 (general health panel) is considered a non-
covered code. 
 
You have requested payment for services billed under code 80050. Medicare does not cover or pay for services 
billed under this code. Therefore, we decided that the Plan does not have to pay for the general health panel 
(80050) provided April 18, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve L4 kyphoplasty (22513). 
 
You asked the Plan to pre-approve L4 kyphoplasty. 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 PVP and PVA will be considered reasonable and 
necessary for osteoporotic conditions when certain 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 L4 kyphoplasty. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found there is no trial of a back brace for 
fracture treatment 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of L4 kyphoplasty have not been met. Therefore, we decided that the Plan does not 
have to pre-approve L4 kyphoplasty (22513).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the INFUSE allograft. 
 
You asked the Plan to pre-approve the INFUSE allograft. You say that this is medically necessary due to the 
enrollee's lower extremity weakness. The Plan denied your request. The Plan says there are not enough studies 
to show that the INFUSE allograft is safe and effective. 
 
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 INFUSE allograft. Our reviewer 
says that the requested INFUSE allograft is 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 requested allograft to be an effective and/or safe treatment for the noted pathology. Further studies are 
needed to demonstrate this request has beneficial outcomes compared with conventional treatment. There is no 
compelling rationale presented or extenuating circumstances noted to support the medical necessity of this 
request as an exception. Therefore, the requested INFUSE allograft 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 INFUSE allograft have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the INFUSE allograft.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 power wheelchair with multiple power 
options (K0861, E2311, E2377, E2313, E0953, E0955, E0956, E1007, E1012, E1028, E2323, E2361, E2607, 
E2620, and K0040). 
 
You asked the Plan to pre-approve a group 3 power wheelchair with multiple power options. 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 power wheelchairs are 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 a group 3 power wheelchair with 
multiple power options. Our reviewer says that the services are not medically necessary. Our physician 
reviewer found provided records document that the enrollee has "80%" right upper extremity grip strength thus 
indicating he has adequate upper extremity strength and function to operate the wheelchair's power options 
with their own switches. Provided records do not support that the enrollee is high risk for skin breakdown (he 
can walk a few steps and "can walk alone occasionally"), has a history of pressure ulcer(s) or has had skin flap 
surgery. Records do not document the enrollee performs bladder self-catheterization or that the enrollee has 
increased muscle tone or spasticity to meet criteria for the power tilt and/or recline and thus the multiple power 
option base. As the requested wheelchair base does not meet Medicare coverage criteria, the requested 
accessories are not covered. 
 
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 group 3 power wheelchair with multiple power options have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a group 3 power wheelchair with multiple 
power options (K0861, E2311, E2377, E2313, E0953, E0955, E0956, E1007, E1012, E1028, E2323, E2361, 
E2607, E2620, and K0040).