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

 
We decided that the Plan does not have to pre-approve Trinity Elite allograft (20930). 
 
You asked the Plan to pre-approve Trinity Elite allograft. You say that this is medically necessary. The Plan 
denied your request. The Plan says medical studies haven't proven that the use of this product during spinal 
surgery is better than standard allograft products. 
 
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 Trinity Elite 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 request to be an effective and/or safe treatment for the noted pathology. Further studies are needed to 
corroborate that the requested Trinity Elite allograft in the cervical spine would be as safe or better than 
standard allograft procedures. 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 Trinity Elite allograft have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Trinity Elite allograft (20930).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve caster ultra, fold down push handles, and handrims. 
 
You asked the Plan to pre-approve caster ultra, fold down push handles, and handrims. You say that you live 
alone and cannot stand or walk on your own. The Plan denied your request. The Plan says the requested items 
are not covered. 
 
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 do not serve a purpose that is primarily medical in nature. This items 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 pre-approve caster ultra, fold down push handles, and handrims.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs (A9270) provided February 2, 
2023. 
 
You asked the Plan to pay for the medication. You say that you ask for processing and approval of payment for 
the medically necessary services provided in good faith to the enrollee. The Plan denied your request. The Plan 
says the medication is not covered as a medical benefit under the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered drugs 
(A9270) provided February 2, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on September 27, 2022. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says you billed with an 
incorrect place of service on the claim. The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. The claim was billed with the laboratory POS code. The records do 
not support that the sample was taken in a laboratory setting. Based on this information, we decided that 
Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not 
have to pay for the lab services provided on September 27, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87798 billed for date of service January 16, 
2023.  
 
You asked the Plan to pay for procedure code 87798. You say that this should be paid due to medical necessity.  
The Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed.  
 
The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 87798 is 13. The MAI value for this code is 3. You billed 19 units of this 
code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were 
actually provided, were correctly coded, and were medically necessary. Based on this information, we decided 
that Medicare rules for coverage of procedure code 87798 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 87798 billed for date of service January 16, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator for 9 months (E0466). 
 
You asked the Plan to pre-approve a ventilator for 9 months. 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 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 for 9 months. Our reviewer 
says that the services are not medically necessary. Our physician reviewer found continuation of the home 
ventilator is not medically necessary. This enrollee's respiratory support needs could be met with bilevel 
positive airway pressure (BiPAP), if compliance can be achieved. There is no demonstration of failure of 
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 
3 months, which allows 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 a ventilator for 9 months have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a ventilator for 9 months (E0466).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a kyphoplasty at T7 and T11 (22513, 22515). 
 
You asked the Plan to pre-approve a kyphoplasty. You say that this procedure is medically necessary. The Plan 
denied your request. The Plan says the requested procedure is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a kyphoplasty is covered when all the criteria listed in 
the Medicare rules section 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 kyphoplasty. Our reviewer says that 
the coverage criteria has not been met. Our physician reviewer found that the enrollee is not hospitalized due to 
the back pain nor is the pain noted to be moderate to severe or worsening. The documentation does not 
corroborate a progression of vertebral body height loss, kyphotic deformity, or the pain having a severe impact 
on her daily functioning. Additionally, the T11 fracture is not greater than 25% vertebral body height loss. Also 
noted is retropulsion at the T11 level. Moreover, multiple other plausible pain generators are evident. 
 
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 kyphoplasty have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a kyphoplasty at T7 and T11 (22513, 22515).
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share amounts for the computed tomography (CT) 
scan for head (70450), emergency department (ED) visit (99285), and ambulance transport (A0425) provided 
on January 25, 2023. 
 
You asked the Plan to waive the cost share amounts for the CT scan, ED visit and ambulance transport. You 
say that you fainted after giving blood. You say that you hit your head, scratched your cheek, and broke your 
glasses. You say that you went to the hospital to be checked out. You also say that you feel this should be paid 
by insurance because it was an accident. The Plan denied your request. The Plan says this cost sharing was 
charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $200 
copayment, a $125 copayment; a $200 copayment for Outpatient diagnostic tests and therapeutic services and 
supplies; Emergency care; Ambulance services.  
 
You have been asked to pay a $200 copayment for the CT scan. This service falls within the Outpatient 
diagnostic tests and therapeutic services and supplies benefit category. You have been asked to pay a $125 
copayment for the emergency room visit. This service falls within the Emergency care benefit category. You 
have been asked to pay a $200 copayment for the ambulance transport. This service falls within the Ambulance 
services benefit category. This means that you have been asked to pay the correct amounts based on your 
contract with the Plan. These cost sharing amounts are a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the cost share amounts for the 
computed tomography (CT) scan for head (70450), emergency department (ED) visit (99285), and ambulance 
transport (A0425) provided on January 25, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87150, 87481, and 87653 billed for date of 
service July 21, 2022. 
 
You asked the Plan to pay for procedure code 87150, 87481, and 87653. You say that you disagree with the 
Plan's denial. The Plan denied your request. The Plan says payment for codes 87150, 87481, and 87653 is 
bundled into payment for other codes. 
 
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 87150 
is a column II code to column I code 87500. We have confirmed that codes 87481 and 87653 are column II 
codes to column I code 87150. 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 codes 87150, 87481, and 87653 billed for date of service July 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99309 billed for date of service March 17, 
2022. 
 
You asked the Plan to pay for procedure code 99309. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says payment for code 99309 is bundled into payment for codes 11042 and 
11044. 
 
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 99309 
is a column II code to column I codes 11042 and 11044. 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 99309 billed for date of service 
March 17, 2022.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home health services (G0299, Q5001) provided on March 23, 2022, to April 21, 2022.

You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree with the denial. The Plan denied your request. The Plan says the NOA was not received timely. As such, this final claim was correctly denied.

The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of care date for home health services. NOAs which are received more than 30 days from the timely filing date result in no payment being made for the episode of care.

In this case, the start of care date is March 23, 2022. The NOA has still not been received. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be made on this claim. Therefore, we decided that the Plan does not have to pay for home health services (G0299, Q5001) provided on March 23, 2022, to April 21, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a kyphoplasty at L1 (22514). 
 
You asked the Plan to pre-approve a kyphoplasty. You say that you are requesting reconsideration of the 
denied authorization. The Plan denied your request. The Plan says the coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that a PVA/kyphoplasty is covered when all of the criteria 
listed in the Medicare rules section has been 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 kyphoplasty. Our reviewer says that 
the coverage criteria has not been met. Our physician reviewer found that the enrollee is not hospitalized and 
there is no indication of worsening pain, progression of vertebral body height loss, greater than 25% vertebral 
body height reduction, kyphotic deformity, or a severe impact on her daily functioning. Moreover, the noted 
MRI demonstrated other plausible causes of her low back pain including stenosis and 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 a kyphoplasty have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a kyphoplasty at L1 (22514).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an inpatient admission. 
 
You asked the Plan to pre-approve the inpatient admission. You say that the enrollee has done a few months of 
physical therapy in the past. You also say that the enrollee has had cortisone injections which did not provided 
significant relief.  The Plan denied your request. The Plan says the requested inpatient admission 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 the inpatient admission. Our reviewer 
says that the requested inpatient admission is not considered medically reasonable and necessary in this case. 
Our physician reviewer found the provided documentation does not support that an inpatient admission is 
medically necessary for the approved 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 the inpatient admission have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an inpatient admission.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the discharge management services provided on January 3, 
2023, billed with code 99239. 
 
You asked the Plan to pay for the discharge services as billed. You say that this should be paid.  The Plan 
denied your request. The Plan says there was no evidence of 31 or more minutes of care provided on the 
discharge date.  
 
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 99239 is hospital discharge day management; more than 
30 minutes. 
 
We find that CPT code 99239 is not supported in the medical record. Specifically, the discharge summary does 
not include documentation of the time spent. Based on this information, we decided that Medicare rules for 
coverage of the discharge services as billed have not been met. Therefore, we decided that the Plan does not 
have to pay for the discharge management services provided on January 3, 2023, billed with code 99239.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve maxillary complete denture (D5110). 
 
You asked the Plan to pre-approve the dental services. You say that your dentures do not fit anymore and cause 
you pain. The Plan denied your request. The Plan says that your benefit for the requested item or service has 
already been exhausted. 
 
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 not sent the necessary information to verify that a maxillary 
complete denture (D5110) was paid for by the Plan on October 18, 2021. Therefore, we decided that the Plan 
has to pre-approve maxillary complete denture (D5110).  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652, E0667). 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says there has been no four week trial of E0650 or E0651.
 
The Plan must follow Medicare rules. Medicare rules say that E0652 is not covered for lymphedema of the 
extremities alone. The lymphedema needs to extend to the chest, trunk and/or abdomen. 
 
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 device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the enrollee has chronic lymphedema of the lower legs. The edema does not extend into the 
enrollee's trunk, abdomen or chest. The enrollee has shown steady progress with skilled therapy. 
 
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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a pneumatic compression device (E0652, E0667).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the inpatient hospital care provided from 
October 28, 2022, to October 30, 2022, and the CT scan provided on January 18, 2023 
 
You asked the Plan to waive the cost share for the inpatient hospital care and the CT scan. You say that you 
cannot afford the cost share. The Plan denied your request. The Plan says this cost sharing was charged 
correctly. 
 
 
 The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $750 deductible which applies to inpatient hospital care. Your 
contract with the Plan also clearly says that you must pay a $325 copayment per day, for days 1 to 4 and a $0 
copayment per day, for days 5 to 90, after your $750 plan deductible, for inpatient services. Your contract with 
the Plan also clearly says that you must pay a $200 copayment for each Medicarecovered CT scan. 
 
You have been asked to pay $750, which satisfies your deductible for the inpatient hospital care. The items or 
services you asked the Plan to waive the deductible for fall within the inpatient hospital care benefit category. 
The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 deductible which 
applies to inpatient hospital care. This cost sharing is a contractual obligation that had not been met at the time 
the inpatient hospital care was received from October 28, 2022, to October 30, 2022. 
 
You have also been asked to pay a $325 copayment per day, for days 1 to 3 of the inpatient hospital stay. You 
have been asked to pay a total of $975 ($325 copayment x 3 days = $975). You have not been charged for any 
additional days. This item/service falls within inpatient hospital care benefit category. You have also been 
asked to pay a $200 copayment for the CT scan. This means that you have been asked to pay the correct 
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay 
when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the cost share for the 
inpatient hospital care provided from October 28, 2022, to October 30, 2022, and the CT scan provided on 
January 18, 2023
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for stent placement, and related services provided on October 
31, 2022. 
 
You asked the Plan to pay for stent placement, and related services. You say that these services were medically 
necessary. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for stent placement, and 
related services provided on October 31, 2022.